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Immunohematology

Journal of Blood Group Serology and Education

Volume 26, Number 2, 2010

Immunohematology

Journal of Blood Group Serology and Education


Volume 26, Number 2, 2010

Contents

47
51
57

Report
Consortium for Blood Group Genes (CBGG): 2009 report
G.A. Denomme, C.M. Westhoff, L. Castilho, M. St-Louis, V. Castro, and M.E. Reid
Review
The Duffy blood group system: a review
G.M. Meny
Original Report
RHCE*ceAR encodes a partial c (RH4) antigen
C. Halter Hipsky, C. Lomas-Francis, A. Fuchisawa, and M.E. Reid

60

Review
The Gerbich blood group system: a review
P.S. Walker and M.E. Reid

66

Original Report
Application of real-time PCR and melting curve analysis in rapid Diego
blood group genotyping
M.C.Z. Novaretti, A.S. Ruiz, P.E. Dorlhiac-Llacer, and D.A.F. Chamone

71

Review
The Dombrock blood group system: a review
C. Lomas-Francis and M.E. Reid

79

Announcements

80

Advertisements

84

Instructions for Authors

Editorial Board

Editors-in-Chief

Sandra Nance, MS, MT(ASCP)SBB


Philadelphia, Pennsylvania

Patricia Arndt, MT(ASCP)SBB


Pomona, California

John J. Moulds, MT(ASCP)SBB


Shreveport, Louisiana

Connie M. Westhoff, PhD, MT(ASCP)SBB


Philadelphia, Pennsylvania

James P. AuBuchon, MD
Seattle, Washington

Paul M. Ness, MD
Baltimore, Maryland

Senior Medical Editor

Martha R. Combs, MT(ASCP)SBB


Durham, North Carolina

Joyce Poole, FIBMS


Bristol, United Kingdom

Geoffrey Daniels, PhD


Bristol, United Kingdom

Mark Popovsky, MD
Braintree, Massachusetts

Geralyn M. Meny, MD
Philadelphia, Pennsylvania

Managing Editor

Cynthia Flickinger, MT(ASCP)SBB


Philadelphia, Pennsylvania

Anne F. Eder, MD
Washington, District of Columbia

Technical Editors

George Garratty, PhD, FRCPath


Pomona, California

Christine Lomas-Francis, MSc


New York City, New York
Dawn M. Rumsey, ART (CSMLT)
Glen Allen, Virginia

Associate Medical Editors


David Moolten, MD
Philadelphia, Pennsylvania
Ralph R. Vassallo, MD
Philadelphia, Pennsylvania

Editorial Assistant

Marion E. Reid, PhD, FIBMS


New York City, New York
S. Gerald Sandler, MD
Washington, District of Columbia

Brenda J. Grossman, MD
St. Louis, Missouri

Jill R. Storry, PhD


Lund, Sweden

Christine Lomas-Francis, MSc


New York City, New York

David F. Stroncek, MD
Bethesda, Maryland

Gary Moroff, PhD


Rockville, Maryland

Emeritus Editorial Board

Delores Mallory, MT(ASCP) SBB


Supply, North Carolina

Patti A. Brenner

Copy Editor

Immunohematology is published quarterly (March, June, September, and December) by the


American Red Cross, National Headquarters, Washington, DC 20006.

Proofreader

Immunohematology is indexed and included in Index Medicus and MEDLINE on the MEDLARS
system. The contents are also cited in the EBASE/Excerpta Medica and Elsevier BIOBASE/
Current Awareness in Biological Sciences (CABS) databases.

Mary L. Tod

Lucy Oppenheim

Production Assistant
Marge Manigly

Electronic Publisher
Wilson Tang

The subscription price is $40.00 (U.S.) and $50.00 (foreign) per year.
Subscriptions, Change of Address, and Extra Copies:
Immunohematology, P.O. BOX 40325, Philadelphia, PA 19106
Or call (215) 451-4902
Web site: www.redcross.org/immunohematology
Copyright 2010 by The American National Red Cross
ISSN 0894-203X

On Our Cover
Bottles and Knife 19111912, Juan Gris
Along with Pablo Picasso, Juan Gris was one of the early innovators of
Cubism, an avant garde movement in the visual arts. In a radical break from
traditional representation, cubist paintings evinced a radical vision and a
remarkable proliferation of perspective in which the surfaces and lines of a
paintings subject were distorted, multiplied, and flattened from a cohesive
whole into manifold planes. In a similar way, advances in immunohematology
elucidating the structure and function of red blood cell surface molecules have
led to simultaneous, coexistent models with diverse planes of understanding
biochemical, antigenic, molecular, genetic, genomic, and microbiologic.
Like the Gris painting, the Duffy glycoprotein represents a break from the
traditional view of the antigen-antibody perspective as it is also a receptor for
multiple chemokines and acts as the portal of entry for Plasmodium vivax.
David Moolten, MD

Report

Consortium for Blood Group Genes (CBGG):


2009 report
G.A. Denomme, C.M Westhoff, L.M. Castilho, M. St-Louis, V. Castro, and M.E. Reid

The Consortium for Blood Group Genes is a worldwide organization whose goal is to have a vehicle to interact, establish guidelines, operate a proficiency program, and provide education for
laboratories involved in DNA and RNA testing for the prediction of blood group, platelet, and neutrophil antigens. Currently, the consortium operates with representatives from Brazil,
Canada, and the United States. Membership is voluntary with
the expectation that members actively contribute to discussions
involving blood group genetics. This year witnessed a change
in the standing committee membership and the institution of
a representative for the human platelet antigens group. Looking forward, the consortium sees challenges for the nomenclature of blood group alleles and user-required specifications for
laboratory information systems to store genotype information.
Immunohematology 2010;26:4750.
Key Words: blood group alleles, Consortium for Blood Group
Genes, proficiency, target alleles

he Consortium for Blood Group Genes (CBGG) is a


not-for-profit organization established in 2004 by a
group of like-minded people with scientific or industry experience and interest in the field of the genetics of red
cell, platelet, and neutrophil antigens, collectively known as
blood group genetics. The mission of the consortium is to
establish guidelines, to provide education, and to provide
a proficiency exchange for laboratories involved in DNA or
RNA testing for the determination of blood group, platelet,
and neutrophil antigens. The consortium is coordinated by
three country representatives: Lilian Castilho (Hemocentro
de Campinas) for Brazil, Maryse St-Louis (Hma-Qubec)
for Canada, and Connie Westhoff (American Red Cross)
for the United States, with Marion Reid (New York Blood
Center) as facilitator and Greg Denomme (BloodCenter of
Wisconsin) as secretary. Vagner Castro is coordinator for
the platelet group. Members are encouraged to refer to the
published CBGG articles for background information and
progress of the consortium.15 Exchange of information is
mainly accomplished through electronic mailings and a
yearly meeting, with proficiency evaluation exercises occurring in the spring and fall of each year.
The CBGG Document
The CBGG Document is the sole information document
for members, is made available by electronic transfer, and
outlines the function of the CBGG. This document contains
information on the structure, organizational rules and bylaws, regulatory compliance plan, preferred terminology,

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

and progress on the working parties including a summary


of the proficiency exchange program (from 2007 to date),
guidelines of practice, DNA repository, funding, forms and
disclaimers, and proposed Web site. It is highly recommended that CBGG members refer to this document for the
aforementioned duties and activities. A meeting is held annually, in part for members to discuss outstanding issues,
to provide input, to accept amendments, and to summarize
the proficiency evaluations.
Regulatory Affairs
CBGG members continue to recognize the importance
of appropriately worded reports, including the use of disclaimers, of molecular analyses for both blood donors and
transfusion recipients. Data from molecular testing continue to be a source of information for the resolution of complex serologic problems, and presently are not intended as
the sole means for patient transfusion management decisions.
As an international consortium, CBGG does not provide
guidance on regulatory affairs; members are responsible for
knowledge of and compliance with the regulations in their
own countries. For US members, we bring to your attention
the Code of Federal Regulations (CFR) Part 864Hematology
and Pathology Devices, Subpart ESpecimen Preparation
Reagents; Sec. 864.4020 Analyte specific reagents.
Allele Nomenclature
The list of target alleles was adopted by the CBGG in
2007 and updated in 2009. The preferred current terminology is listed under the heading Target antigen (target
allele) in Table 1 of this report. However, the final naming
of alleles awaits the decision of the International Society for
Blood Transfusion. When referring to a particular single
nucleotide change, it is important to follow the designated
notation, e.g., 125G>A, with intronic nucleotide changes
represented in the lower case, e.g., 67t>c. The associated amino acid substitutions flank the designated position
number, e.g., Pro103Ser or P103S. Because gene numbering systems vary, and to avoid ambiguity in the location of
nucleotide changes, the CBGG has adopted GenBank gene
reference sequences (RefSeqGene) and reference SNP numbers (rs#) for blood group genes and nucleotides (Table 1).
These numbers refer to a set of common documents used
to communicate or report molecular testing results and are
linked to other GenBank reference files.

47

G.A. Denomme et al.

Table 1. List of targets and recommended controls for prediction of certain RBC antigens
ISBT system name
(symbol) number

Target antigen
(target allele)

ISBT gene name


(RefSeqGene)

Target nucleotide
(SNP rs#)

ABO (ABO)
001

A (ABO*A1)

ABO
(NG_006669.1)

consensus

A2 (ABO*A2)
B (ABO*B1)

MNS (MNS)
002

Rh (RH)
004

Lutheran (LU)
005
Kell (KEL)
006

Duffy (FY)
008
Kidd (JK)
009
Diego (DI)
010
Yt (YT)
011
Scianna (SC)
013
Dombrock (DO)
014
Colton (CO)
015
Landsteiner-Wiener
(LW) 016
Cromer (CR)
021
Knops (KN)
022

Indian (IN)
023
OK (OK)
024

O (ABO*O1)
M (GYPA*M)
N (GYPA*N)
S (GPB*S)
s (GPB*s)
S silenced
D
C (RHCE*C)
c (RHCE*c)
E (RHCE*E)
e (RHCE*e)
CW
CX
V & VS
V (VS)
Lua (LU*01 or LU*A)
Lub (LU*02 or LU*B)
K (KEL*01)
k (KEL*02)
Kpa (KEL*03)
Kpb (KEL*04)
Jsa (KEL*06)
Jsb (KEL*07)
Fya (FY*01 or FY*A)
Fyb (FY*02 or FY*B)
Fyx (FY*265T)
Fy null (RBC)
Jka (JK*01 or JK*A)
Jkb (JK*02 or JK*B)
Dia (DI*01 or DI*A)
Dib (DI*02 or DI*B)
Yta (YT*01 or YT*A)
Ytb (YT*02 or YT*B)
Sc1 (SC*01)
Sc2 (SC*02)
Doa (DO*01 or DO*A)
Dob (DO*02 or DO*B)
Hy (HY)
Joa (JO)
Coa (CO*01 or CO*A)
Cob (CO*02 or CO*B)
LWa (LW*05 or LW*A)
LWb (LW*07 or LW*B)
Cra (CR*01 or CR*A)
Kn (KN*01 or KN*A)
Knb (KN*02 or KN*B)
McCa (KN*03)
McCb (KN*06)
Sla (KN*04)
Vil (KN*07)
Ina (IN*01 or IN*A)
Inb (IN*02 or IN*B)
Oka (OK*01 or OK*A)
a

GYPA
(NG_007470.2)
GYPB
(NG_007483.1)
RHD
(NG_007494)
RHD
RHCE
(NG_009208)

nt 1061C (rs56392308)
nt 526C>G (rs7853989)
nt 703G>A (rs8176743)
nt 796C>A (rs8176746)
nt 803G>C (rs8176747)
nt 261G/G (rs8176719)
nt 59C>T;71G>A;72T>G
(rs7682260;7687256;
7658293)

Controls and comments (monitor assay performance with DNA controls known to be homozygous and heterozygote for both alleles unless
otherwise noted)
Targets for nondeletional (261G) ABO*O alleles
are not listed. Various alleles have been described
and multiple targets or sequencing is required for
identification.

Position 72 is the 3rd nt of codon 24 (not for clinical use).

nt 143T>C (rs7683365)
nt 230C>T, intron 5+5g>t
Exon 4 and 7

230T/T not required, I5+5t/t not required


Targets may vary as there are many approaches.

Exon 4 37-bp insert


intron 2 insertion
nt 307T>C (rs676785)
nt 676C>G (rs609320)
nt 122A>G
nt 106G>A
nt 733C>G (rs1053361)
nt 1006G>T

LU
(NG_007480.1)
KEL
(NG_007492.1)

122G/G not required


106A/A not required
733G/G not required
1006T/T not required

nt 230A>G (rs28399653)
nt 578T>C (rs8176058)
nt 841T>C (rs8176059)
nt 1790C>T (rs8176038)

FY
(NG_011626.1)

nt 125G>A (rs12075)
nt 265C>T (rs34599082)
nt -67t>c (rs2814778)

JK
(NG_011775.1)
DI
(NG_007498.1)
YT
(NG_007474.1)
SC
(NG_008749.1)
DO
(NG_007477.1)

nt 838G>A (rs1058396)

265T/T not required


GATA nucleotide change
Testing for nulls may be appropriate in some situations.

nt 2561T>C (rs2285644)
nt 1057C>A (rs1799805)
nt 169G>A (rs56025238)

169A/A not required

nt 793A>G (rs11276)
nt 323G>T (rs28362797)
nt 350C>T (rs28362798)

CO
(NG_007475.1)
LW
(NG_007728.1)

nt 134C>T (rs28362692)

134T/T not required

nt 308A>G

308G/G not required

CROM
(NG_007465.1)
KN
(NG_007481.1)

nt 679G>C (rs60822373)

IN
(NG_008937.1)
OK
(NG_007468.1)

nt 4681G>A (rs41274768)
nt 4768A>G (rs17047660)

4768G/G not required

nt 4801A>G (rs17047661)

4801G/G not required

nt 252C>G
nt 274G>A

Homozygous mutated and heterozygote not


required

Predicted antigen negativity should be confirmed by hemagglutination with licensed reagents if available, with unlicensed reagents if available,
or by a crossmatch performed by the laboratory issuing the product to the patient.
Numbering of nucleotide (nt) is based on A of AUG

48

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

002a. CBGG Proficiency Exchange Program Result Form - author corrections 060410.pdf

Guidelines for Molecular Testing


The CBGG published ISO format guidelines for molecular testing for blood groups in 2007. The AABB standards
for molecular testing for red cell, platelet, and neutrophil
antigens was published in 2008.6,7 AABB is currently assembling accreditation guidelines and training accreditors
to certify laboratories that perform molecular testing for
red cell, platelet, and neutrophil antigens. The intent of the
CBGG is to remain as an independent forum and voice for
molecular testing guidelines in ISO format for use by international laboratories. The members will update, modify, or
otherwise amend the CBGG guidelines by process of discussion and consensus. The CBGG guidelines will not become standards as such to reflect the fact that the CBGG is
not responsible for laboratory inspection or accreditation.
C

CBGG Proficiency Exchange Program Result Form

Date sent: _________________________

Date due: _________________

Originating Laboratory:
Receiving Laboratory:
Name: __________________________
__________________________
Address: __________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Phone #: __________________________
__________________________
Fax #: __________________________
__________________________
DNA Sample ID: _____________ Molecular Assay Requested: [JK*A/B or JK*01/02]
Receiving (Testing) Laboratory:
Date sample arrived: ____________________
DNA Result
Technologist
Supervisor
Predicted
DNA Method
Phenotype
(Genotype)
Date
Date
[AS-PCR]

[JK*A/JK*B]

[Jk(a+b+)]

MY

Proficiency Program
As of spring 2008, the alleles of RBC antigens for proficiency exchanges are currently restricted to RHCE*E/
RHCE*e, GYPB*S/GYPB*s, KEL*1/KEL*2, FY*A/FY*B,
FY*67C/T GATA, and JK*A/JK*B. The cost of sample
preparation and shipping the DNA sample is borne in turn
by each submitting laboratory. To participate in the sample exchange, proficiency program members must agree
to provide a sample for distribution in a subsequent year
through a predetermined rotation. Although participation
in the CBGG proficiency program mandates that samples
be discarded after the results have been validated, proficiency program members must ensure they comply with
the requirements of regulatory bodies. Thus, before joining the proficiency exchange program and committing to
supplying a sample for the exchange, new members should
address their institutional requirements on informed
consent. To prevent communication errors caused by different reporting mechanisms, a report form has been
developed specifically for the CBGG proficiency program,
a copy of which is provided in Figure 1 with examples. The
proficiency evaluations for platelets and neutrophils are
distributed among a group of members headed by Vagner
Castro (Platelet Immunology Laboratory of Hematology
and Hemotherapy Center of the State University of Campinas, UNICAMP, Campinas, So Paulo, Brazil). Serologic
confirmation is not mandated by this group because of the
lack of regulated antisera.

CBGG: 2009 report

1:00:20 PM

NOTE: Report results on this Form and use the nucleotide designation from List of
Targets. in the current CBGG Document.

CM

7/13/10

[Signature]

[Signature]

[Date]

[Date]

Comments/Disclaimers:

CY

CMY

Electronic Data Records and Databases


Members of the CBGG have recognized the need to
provide manufacturers of electronic laboratory information systems (LIS) with appropriate input as they make
decisions on changes to their operating systems. Presently,
LIS do not have place-holder fields for genotype results or
the capability to compare the DNA test result to the phenotype when available. Neither do algorithms exist to make
phenotype predictions from the DNA test results. The

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Originating (Verification) Laboratory:


Acceptable response: ______________________________________________________
DNA Method
[PCR-RFLP]

DNA Result
(Genotype)
[JK*A/JK*B]

Reviewed by:

Actual Phenotype
[Jk(a+b+)]

Date
[Name]
[Date]

Comments/Disclaimers:

Acknowledgement of verified results: ________________________________________

Originating Laboratory: Complete all information for the receiving laboratory to perform testing.
Testing Laboratory: Fill in testing information; sign and date. Fax form to submitting laboratory.
Submitting Laboratory: Fill in results of submitting laboratory, sign and date. Fax verification to
testing lab.
NOTE: Discard DNA as soon as verification is received

Fig. 1. Example of the CBGG proficiency exchange program result


form.

CBGG members also discussed that a position paper from


the CBGG could be developed to outline what users desire
from manufacturers of DNA testing platforms and what
nucleotide targets are needed to define a predicted antigen
phenotype. It was recommended that a focus group be assembled to address LIS user requirements.
Conclusions
The CBGG is a self-help, not-for-profit organization
designed as an interactive collaborative for members to
learn from each other and to strive to achieve excellence
in molecular testing of blood group, platelet, and neutrophil antigens. Anyone interested and willing to contribute
intellectually is welcome to join. Important information
on analyte specific reagents in the context of laboratorydeveloped tests, decisions on the specifications of information systems, and the appropriate targets for molecular
testing are important topics for discussion in 2010.

49

G.A. Denomme et al.

Acknowledgments

We thank Robert Ratner for help in the preparation of
this manuscript. The findings and conclusions in the article
should not be construed to represent any agency determination or policy.
References
1. Denomme G, Reid M. Inaugural meeting of the Consortium for Blood Group Genes (CBGG): a summary
report. Immunohematology 2005;21:12931.
2. Reid ME. Consortium for Blood Group Genes. Transfusion 2007;47(Suppl):98S100S.
3. Reid ME, Westhoff CM, Denomme G, Castilho L. Consortium for Blood Group Genes (CBGG): Miami 2006
report. Immunohematology 2007;23:814.
4. Reid ME, Westhoff C, Denomme G, Castilho L. Consortium for Blood Group Genes (CBGG): 2007 report.
Immunohematology 2007;23:1658.
5. Denomme GA, Westhoff CM, Castilho L, Reid ME. Consortium for Blood Group Genes (CBGG): 2008 report.
Immunohematology 2009;25:7580.
6. Molecular Testing Standards Program Unit. Standards
for molecular testing for red cell, platelet, and neutrophil antigens. Bethesda, MD: AABB Press, 2008.

7. Molecular Testing Standards Program Unit. Guidance


for standards for molecular testing for red cell, platelet,
and neutrophil antigens. Bethesda, MD: AABB Press,
2009.
Gregory A. Denomme, PhD, Immunohematology Reference Laboratory, BloodCenter of Wisconsin, 638 N 18th
Street, PO Box 2178, Milwaukee, WI 53201-2178; Connie
M. Westhoff, PhD, Molecular Blood Group and Platelet
Antigen Testing Laboratory, American Red Cross-PennJersey Region, Philadelphia, PA; Lilian Maria de Castilho,
PhD, Laboratory of Immunohematology, Hemocentro
State University of Campinas (UNICAMP), Campinas, So
Paulo, Brazil; Maryse St-Louis, PhD, Research and Development, Operational Research, Hma-Qubec, Qubec,
Canada; Vagner Castro, PhD, Laboratory of Platelet Immunology, Hematology and Hemotherapy Center, Instituto Nacional de Cincia e Tecnologia do Sangue (INCTS),
State University of CampinasUNICAMP, Campinas, So
Paulo, Brazil; and Marion E. Reid, PhD, Laboratory of Immunochemistry and Laboratory of Immunohematology,
New York Blood Center, New York, NY.

Manuscripts
The editorial staff of Immunohematology welcomes manuscripts pertaining to blood group serology and education for consideration for publication. We are especially interested in case reports, papers on platelet and white
cell serology, scientific articles covering original investigations, and papers on new methods for use in the blood
bank. Deadlines for receipt of manuscripts for consideration for the March, June, September, and December
issues are the first weeks in November, February, May, and August, respectively. For instructions for scientific
articles, case reports and review articles, see Instructions for Authors in every issue of Immunohematology or on
the Web at www.redcross.org/immunohematology. Include fax and phone numbers and e-mail address with all
articles and correspondence. E-mail all manuscripts to immuno@usa.redcross.org.

Attention: State Blood Bank Meeting Organizers


If you are planning a state meeting and would like copies of Immunohematology for distribution, please send
request, 4 months in advance, to immuno@usa.
redcross.org.

50

For information concerning Immunohematology,


Journal of Blood Group Serology and Education, or
the Immunohematology Methods and Procedures
manual, contact us by e-mail at immuno@usa.
redcross.org.

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Review

The Duffy blood group system: a review


G.M. Meny
Duffy was the first blood group mapped to an autosome (chromosome 1) using cytogenetic studies. Duffy antigens are located on
a glycoprotein that can be found on erythrocytes and other cells
throughout the body. Fya and Fyb are products of their respective
alleles (FY*A, FY*B). Fyx, characterized by weak Fyb expression, is
a result of an additional mutation in FY*B. The Fy(ab) phenotype, most commonly found in Blacks, occurs primarily as a result
of a GATA promoter region mutation upstream of the FY allele.
This mutation prevents expression of Duffy glycoprotein on erythrocytes only, while permitting expression on nonerythroid cells.
Other antigens include Fy3, Fy5, and Fy6. Antibodies to Duffy
antigens are usually clinically significant and have been reported
to cause hemolytic disease of the fetus and newborn. This review
provides a general overview of the Duffy blood group system, including the role of the Duffy glycoprotein as a chemokine receptor
(Duffy antigen receptor for chemokines) and in malarial infection.
Immunohematology 2010;26:5156.

study. The Un locus causes chromosome 1 to have an unusual lengthy appearance when viewed in metaphase. Describing a family with an inversion break point provided
additional evidence for assigning the Duffy locus to chromosome 1.
Genetics and Inheritance
Both FY and RH gene loci reside on chromosome 1.
However, the FY locus is located on the long arm at position 1q22 q23, whereas RH resides on the short arm.5 Fya
and Fyb are antithetical antigens produced by codominant
alleles, FYA and FYB. Four phenotypes are defined by the
corresponding antibodies, anti-Fya and anti-Fyb (see Table
1). The Duffy system antigens are listed in Table 2.
Table 1. Duffy phenotypes, prevalence, and inherited alleles

Key Words: Duffy antigen receptor for chemokines, DARC,


FYA, FYB

History
he initial description related to the Duffy blood group
system was published in 1950 when anti-Fya was
observed during an investigation of a hemolytic
transfusion reaction.1,2 The antibody was described in a
43-year-old group O, D individual with hemophilia who
received a 3-unit transfusion for treatment of an episode
of spontaneous bruising and bleeding. The transfusions
were followed by rigors. Jaundice developed the day after
transfusion. Investigation revealed an antibody that was
detected only by the IAT and was named anti-Duffy (antiFya) after the patient. An Fya phenotype frequency of 64.9
percent was calculated, and gene frequencies for both Fya
and the hypothetical Fyb were described.
One year later, anti-Fyb was discovered by Ikin et al.3
in a patient 2 days after the birth of her third child. None
of the children were noted to show signs of HDN. Antibody
investigations demonstrated that stronger reactions were
observed when the antibody was tested in the presence of
albumin than of saline and at 37C than at room temperature. Confirmation of a previously calculated Fyb phenotype
frequency was noted. Of interest, the authors speculated on
the possibility of a rare third allele, which would react with
neither antibody.
Duffy was the first blood group locus to be assigned to an
autosome (a nonsex chromosome). Investigators performed
linkage analysis between serologic blood typing results and
cytogenetic studies on four families, one of which was a
three-generation family.4 The Duffy locus segregated with
the uncoiler (Un) locus on chromosome 1 in three family
studies and an inversion of chromosome 1 in one family

Red cell
phenotype

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Prevalence %
Caucasians
Blacks

Allele

10

FY*01/FY*01 or
FY*A/FY*A

Fy(a+b)

20

Fy(ab+)

32

20

FY*02/FY*02 or
FY*B/FY*B

Fy(a+b+)

48

FY*A/FY*B

Fy(ab)

Very rare

67

FY*/N.0105,
FY*/N.0102

Present in 7090% of some Asian populations.


Nomenclature pending approval by the ISBT Working Party on
Terminology for Red Cell Surface Antigens
Table modified from Daniels.6,7

Table 2. Duffy antigens7


Antigen

ISBT symbol

ISBT no.

Fya

FY1

008001

Fy

FY2

008002

Fy3

FY3

008003

Fy

FY4

008004

Fy5

FY5

008005

Fy

FY6

008006

The Fy(ab) phenotype is the major phenotype


in Blacks, but is very rarely found in Caucasians. The phenotype found in Blacks is characterized by the presence of
Fyb antigen on nonerythroid cells, but an absence of the Fyb
antigen on RBCs.8 A mutation in the erythroid promoter
GATA-1 binding motif explains why Fy(ab) individuals
do not make anti-Fyb (see Molecular section). The Fy(ab)
phenotype found in Caucasians is characterized by a lack of

51

G.M Meny

Duffy antigen expression in both erythroid and nonerythroid tissues. Different mutations are present in either the
FYA or FYB gene, which prevent the Duffy protein from being formed. These individuals, interestingly, tend to form
anti-Fy3.911

Other alleles have been reported at the FY locus. The
Fyx phenotype is associated with weak expression of Fyb,
Fy3, and Fy5 antigens. Chown et al.12 first reported the Fyx
gene and estimated the phenotype frequency in a Caucasian
population was not more than 2 percent. It is now known
that Fyx is caused by a point mutation in the FYB gene.13,14
Antibodies in the System
Anti-Fya and -Fyb

Anti-Fya and -Fyb are found after transfusion or, less frequently, as a result of pregnancy. They are rarely naturally
occurring. Duffy antibodies are predominantly of the IgG1
subclass, and 50 percent of anti-Fya examples bind complement. Anti-Fyb, identified about 20 times less frequently
than anti-Fya, is usually present in sera with other alloantibodies.15 Both antibodies cause immediate and delayed
hemolytic transfusion reactions.16 When Fy(ab) Black
individuals develop Duffy antibodies, they usually produce
anti-Fya, which may be followed by anti-Fy3 or anti-Fy5.17,18
Anti-Fyb is not produced.

With regard to hemolytic disease of the fetus and newborn (HDFN), anti-Fya was identified in 5.4 percent of
atypical alloantibodies in a group of women receiving obstetric care at a tertiary-care center. Of antibodies capable
of causing HDFN, Kell blood group antibodies were identified most frequently (22%). In contrast, anti-Fyb was infrequently identified (0.2%). This compares with 0.5 percent
to 3.1 percent of Duffy system antibodies detected in four
other series of obstetric patients.19

Hughes et al.20 reviewed the clinical outcome of 18
pregnant women between 1959 and 2004 in whom antiFya was the only alloantibody identified and the fetus was
Fy(a+). Significant HDFN was identified in 2 of 18 (11%)
pregnancies, resulting in exchange transfusion or intrauterine transfusion. Maximum serum titers in these cases were
32 and 128. Hydrops fetalis was not identified in any fetus,
and no deaths attributable to HDFN were reported. A rare
case of HDFN caused by anti-Fyb has been reported.21
Anti-Fy3, -Fy4, -Fy5, and -Fy6

Anti-Fy3 was first described by Albrey et al.9 in a Caucasian individual who was pregnant with her third child. The
authors noted that this antibodys reactivity suggests that
the Duffy system is more complicated than it seemed before. Anti-Fy3 was unique in that it reacted with enzymetreated Fy(a+) or Fy(b+) RBCs, but failed to react with
Fy(ab) RBCs from Black individuals. Clinically, the baby
was reported to have mild HDFN (weakly positive DAT),
but no treatment was required.

Subsequent reports of anti-Fy3 have also been described in Black individuals during investigation of acute or
52

delayed hemolytic transfusion reactions.17,22,23 Of interest,


Vengelen-Tyler17 noted that anti-Fy3 developed after antiFya in individuals receiving multiple RBC transfusions for
treatment of sickle cell disease, and Olteanu et al.22 reported a case of an acute hemolytic transfusion reaction caused
solely by anti-Fy3 in an 8-year-old Black individual treated
for repair of a femoral neck fracture.

The only example of anti-Fy4 was described by Behzad
et al.24 in a 12-year-old patient with sickle cell disease. This
antibody appeared to react with Fy(ab), some Fy(a+b)
or Fy(ab+), but no Fy(a+b+) RBCs. However, the existence
of this antibody is in doubt owing to the lack of consistent
test results between laboratories and sample instability on
storage and shipment.

Colledge et al.25 reported the first example of anti-Fy5 in
an 11-year-old Fy(ab) Black individual who died of acute
leukemia shortly after the antibody was discovered. Like
anti-Fy3, anti-Fy5 reacted with enzyme-treated Fy(a+) or
Fy(b+) RBCs. No reactivity was seen with Fy(ab) RBCs
from Black individuals, or Rhnull cells with normal expression of Fya and Fyb antigens. One Fy(ab) RBC sample
from a Caucasian individual was positive. Anti-Fy5 is reported to cause delayed hemolytic transfusion reactions in
patients with sickle cell disease who develop this antibody
in conjunction with other blood group antibodies such as
anti-Fya,17,26 and anti-K, -E, and -C.27

No human anti-Fy6 has been identified. Monoclonal
antibodies have been raised against Fy6 epitopes, as well as
other Duffy blood group epitopes.2830
Biochemistry

The Duffy protein is composed of 336 amino acids. The
numbering of amino acids (and nucleotides) has varied because two kinds of Duffy mRNA have been described: a less
abundant form, that was the first to be discovered and cloned,
encodes a protein of 338 amino acids whereas the more abundant form encodes a protein of 336 amino acids and is the
form that is represented in Figure 1.31,32 The Duffy protein is
likely organized in the RBC membrane as an N-glycosylated
protein that spans the membrane seven times (Fig. 1). Fya and
Fyb differ by a single amino acid change at position 42 on the
extracellular domain, with glycine resulting in Fya expression
and aspartic acid resulting in Fyb expression.5,33 Both Fya and
Fyb are sensitive to destruction when RBCs are treated with
proteolytic enzymes such as papain or ficin. Trypsin treatment
of RBCs does not result in destruction of Fya or Fyb.6

The Fy(ab+w) phenotype is associated with weak Fyb,
Fy3, and Fy6 expression. This phenotype results from a mutation in the FYB gene. The Fyx-associated mutation at position 89 in the first cytoplasmic loop (Fig. 1) causes the Duffy
protein to be unstable. This intracellular amino acid change
causes a quantitative reduction in the amount of Duffy protein
and, hence, a decreased amount of Fyb, Fy3, and Fy6 expression. The Arg89Cys change was found in 3.5 percent of Caucasians, but was not found in Blacks. Another mutation in the
same area (Ala100Thr) does not alter Duffy expression.13,34
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Duffy blood group system

Fig. 1. The predicted Duffy glycoprotein seven-transmembrane


domain structure. Amino acid changes responsible for the Fya/
Fyb polymorphism, the Fyx mutation, and Fy3 and Fy6 regions are
indicated. N-glycosylation sites are shown as Y. Reprinted with
permission from Westhoff and Reid.32


The epitopes identified by monoclonal antibodies to
Fy3 and Fy6 have been characterized. The Fy3 epitope is
present on the third extracellular loop.35 Fy3, like Fy5, is
resistant to destruction when RBCs are treated with proteolytic enzymes.6 The Fy6 epitope is located N-terminal to
the Fya/Fyb site and is composed of multiple amino acids
located between positions 19 and 25.28 Unlike Fy3, Fy6 is
destroyed when RBCs are treated with proteolytic enzymes.
Like Fya and Fyb, trypsin treatment of RBCs does not result
in destruction of Fy6.6
Molecular
FYA and FYB

The biochemical differences in Fya and Fyb antigens
can be explained at a molecular level by a single nucleotide
substitution. This substitution (G codes for Fya and A codes
for Fyb) allowed DNA typing of the main Duffy antigens to
be performed as the FY*A sequence correlated with a BanI
restriction site.36
Fy(ab) Phenotype

The Fy(ab) phenotype, detected in approximately 70
percent of Black individuals, is identified very rarely in Caucasians. The molecular basis for this disparity is not only
interesting from a scientific perspective, but has clinical implications as well (see Clinical Significance). Erythroid-only
suppression of Duffy antigen expression occurs because of a
point mutation in the GATA-1 binding site in Black individuals who have the Fy(ab) phenotype.8 GATA sequences
are plentiful in the genome and function as promoters of
many genes, including those involved in hematopoiesis.37
The mutation present in the GATA promoter region of
FY*B (67, T to C) disrupts a binding site for the GATA-1
erythroid transcription factor. A similar mutation has been
identified in the GATA-1 promoter region of FY*A as well.38
Duffy antigen expression is prevented on erythrocytes, but

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

not on other cells.39 Thus, Duffy mRNA can be detected in


nonerythroid cells such as lung, spleen, and colon of Black
individuals with a mutated GATA box. However, bone marrow cells from the same individuals are negative for Duffy
mRNA expression.

The genetic mutations found in Fy(ab) Caucasians
do not resemble those identified in Black individuals. Three
individuals from multiple ethnic backgrounds (Cree Indian, Lebanese Jewish, and Caucasian English) were found to
have point mutations that encoded premature stop codons
in either FY*A or FY*B. These mutated genes, if translated
into proteins, result in unstable products that are quickly
degraded. Thus, the Duffy proteins in Caucasian individuals are absent from all tissues, including RBCs.11
Clinical Significance
Duffy Glycoproteins and Chemokines

Chemokines are proteins secreted by cells, such as immune cells, which are used as communication signals to
guide their interactions.40 Chemokine messages secreted
from one cell are received and decoded by another cell via
specific receptors, leading to various responses such as
leukocyte chemotaxis and adhesion. Similar to the Duffy
glycoprotein, many chemokine receptors have seven transmembrane domains. However, whereas other chemokine
receptors specifically bind chemokines of a single class, the
Duffy glycoprotein was found to bind a variety of chemokines and is known as the Duffy antigen receptor for chemokines (DARC).41,42

The function of DARC is yet to be clearly defined. It has
been suggested that DARC may permit the erythrocyte to
serve as a chemokine sink or scavenger, thus limiting activation of leukocytes in the systemic circulation. However,
it is unclear how long chemokines remain bound to the cell
surface or what happens to the chemokines at the end of
the erythrocyte lifespan. In addition, it is unclear as to the
importance of this function in inflammatory or infectious
disease as Fy(ab) erythrocytes do not bind chemokines,
although Fy(ab+w) erythrocytes bind reduced amounts
compared with Fy(ab+) cells.34,4143
DARC and Renal Disease

If DARC serves as a scavenger or chemokine sink as part
of an effort to limit inflammation, what role could DARC
play in modulating an immune response in renal disease
and renal transplantation? Using an anti-Fy6 monoclonal antibody, Liu et al.44 performed immunohistochemical
studies of renal biopsies from children with renal disease
to examine Duffy antigen expression. Renal cell DARC expression was found to be upregulated in multiple causes of
renal cell injury, including HIV nephropathy and hemolytic
uremic syndrome. The authors speculate that the increased
DARC expression may be the kidneys attempt to bind and
neutralize chemokines and control inflammation. They also

53

G.M Meny

speculate that the high incidence of HIV nephropathy in


Black individuals may thus be associated with the Fy(ab)
phenotype.

Other groups have attempted to find a correlation between Duffy antigen expression and renal graft survival, with
mixed results. Akalin and Neylan45 found Duffy-negative
graft recipients had lower allograft survival compared with
recipients of other phenotypes and speculated that a loss
of ability to bind chemokines leads DARC-negative recipients to be more vulnerable to poor graft function. Mange et
al.46 did not confirm an association between a graft recipient with a null DARC phenotype and an increased incidence
of acute renal allograft rejection or delayed graft function.
One recent paper examined Duffy antigen mismatches between recipient and donor renal transplants and suggests a
potential role for Duffy as a minor histocompatibility antigen.47
DARC and Malaria

In addition to serving as a chemokine receptor, the
Duffy glycoprotein has been shown to be the erythroid receptor for Plasmodium vivax and Plasmodium knowlesi.
Initially, P. knowlesi, a monkey malaria parasite, was used
as an in vitro model to study human malaria. However,
Miller et al.48 performed blood typing on 11 volunteers exposed to P. vivaxinfected mosquitoes and found that those
who contracted malaria were Fy(a+) or Fy(b+), whereas
those whose erythrocytes were resistant to parasitic invasion were Fy(ab). Evidence has since shown that the P.
vivax Duffy-binding protein (PvDbp) interacts with Duffy
antigens on RBCs to permit RBC infection and that PvDbp
may be a candidate for vaccine development.49

P. vivax malaria is the most widely distributed malaria in the world, with approximately 70 to 80 million cases
occurring per year.50 Individuals with the Fy(ab) phenotype may have a selective advantage in that their RBCs
are resistant to P. vivax invasion. This is evident in West
Africa, where P. vivax malaria is absent and greater than
95 percent of the population is Fy(ab). However, a few
contradictions to a genetic adaptation hypothesis remain
to be explained: the Fy(ab) phenotype is not common in
Southeast Asia, another endemic area of P. vivax malaria,
and P. vivax malaria infection is not lethal.5,50
The Clinical Value of Duffy Genotyping

The use of Duffy DNA-based genotyping determinations can be an adjunct to traditional phenotyping in clinical
situations such as assessing for risk of HDFN and locating
matched blood for alloimmunized patients. Goodrick et
al.51 noted that although anti-Fya rarely causes significant
HDFN, the ability to perform Duffy genotyping of fetal amniocytes can be of benefit when the father is heterozygous
for FY*A. Regularly transfused patients, such as individuals

54

with sickle cell disease, and any patient who makes one alloantibody are at a higher risk of forming multiple antibodies.52 Duffy genotyping may be of assistance in providing
matched blood by determining, for example, which Fy(a
b) patients carry the GATA-1 mutation in the promoter region of FY*B, as it is theorized that they can receive Fy(b+)
blood without risk of forming anti-Fyb or anti-Fy3.53 Issues
to consider in the use of Duffy genotyping include the need
to detect silencing mutations, the potential for contamination of PCR-based assays, and the importance of correlating
genotype results with phenotype results.
Summary
Kell Kills, Duffy Dies, Lewis Lives
Medical student mantra related to alloantibody clinical significance


Many of the important discoveries in blood group serology in the first half of the last century were descriptive in
nature and focused on identification of RBC antigens and
the clinical significance of their corresponding antibodies.
The Duffy blood group system illustrates the progress made
in elucidating the structure and function of blood group
antigens. The Duffy glycoprotein acts as an erythrocyte receptor for certain malarial parasites and as a chemokine
receptor (DARC). DARC may play a role in modulating the
effects of certain renal diseases, as well as other disease
states such as HIV54 or malignancy.55 Although significant
progress has been made, much research remains to be completed to understand the structure and function of DARC.
Acknowledgment

The author thanks Connie Westhoff for her discussion
and helpful comments during preparation of this manuscript.
References
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C. Study of anti-Fya in five black Fy(ab) patients. Vox
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19. Geifman-Holtzman O, Wojtowycz M, Kosmas E, Artal
R. Female alloimmunization with antibodies known to
cause hemolytic disease. Obstet Gynecol 1997;89:2725.
20. Hughes LH, Rossi KQ, Krugh DW, OShaughnessy RW.
Management of pregnancies complicated by anti-Fy(a)
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21. Vescio LA, Faria D, Rogido M, Sla A. Hemolytic disease of the newborn caused by anti-Fyb. (Letter) Transfusion 1987;27:366.

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22. Olteanu H, Gerber D, Partridge K, Sarode R. Acute


hemolytic transfusion reaction secondary to anti-Fy3.
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24. Behzad O, Lee CL, Gavin J, Marsh WL. A new antierythrocyte antibody in the Duffy system: anti-Fy4. Vox
Sang 1973;24:33742.
25. Colledge KI, Pezzulich M, Marsh WL. Anti-Fy5, an
antibody disclosing a probable association between
the Rhesus and Duffy blood group genes. Vox Sang
1973;24:1939.
26. Bowen DT, Devenish A, Dalton J, Hewitt PE. Delayed
haemolytic transfusion reaction due to simultaneous appearance of anti-Fya and anti-Fy5. Vox Sang
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27. Chan-Shu SA. The second example of anti-Duffy5.
Transfusion 1980;20:35860.
28. Waniowska K, Blanchard D, Janvier D, et al. Identification of the Fy6 epitope recognized by two monoclonal antibodies in the N-terminal extracellular portion
of the Duffy antigen receptor for chemokines. Mol Immunol 1996;33:91723.
29. Wasniowska K, Petit-LeRoux Y, Tournamille C, et al.
Structural characterization of the epitope recognized by
the new anti-Fy6 monoclonal antibody NaM 1852C3.
Transfus Med 2002;12:20511.
30. Wasniowska K, Lisowska E, Halverson GR, Chaudhuri
A, Reid ME. The Fya, Fy6 and Fy3 epitopes of the Duffy
blood group system recognized by new monoclonal
antibodies: identification of a linear Fy3 epitope. Br J
Haematol 2004;124:11822.
31. Iwamoto S, Li J, Omi T, Ikemoto S, Kajii E. Identification
of a novel exon and spliced form of Duffy mRNA that is
the predominant transcript in both erythroid and postcapillary venule endothelium. Blood 1996;87:37885.
32. Westhoff CM, Reid ME. Review: the Kell, Duffy,
and Kidd blood group systems. Immunohematology
2004;20:3749.
33. Chaudhuri A, Zbrzezna V, Johnson C, et al. Purification
and characterization of an erythrocyte protein complex
carrying Duffy blood group antigenicity. Possible receptor for Plasmodium vivax and Plasmodium knowlesi
malaria parasite. J Biol Chem 1989;264:137704.
34. Yazdanbakhsh K, Rios M, Storry JR, et al. Molecular
mechanisms that lead to reduced expression of Duffy
antigens. Transfusion 2000;40:31020.
35. Lu ZH, Wang ZX. Horuk R, et al. The promiscuous
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36. Tournamille C, Le Van Kim C, Gane P, Cartron JP, Colin Y.


Molecular basis and PCR-DNA typing of the Fya/fyb blood
group polymorphism. Hum Genet 1995;95:40710.
37. Ferreira R, Ohneda K, Yamamoto M, Philipsen S.
GATA1 function, a paradigm for transcription factors
in hematopoiesis. Mol Cell Biol 2005;25:121527.
38. Zimmerman PA, Wooley I, Masinde GL, et al. Emergence of FY*Anull in a Plasmodium vivax-endemic region of Papua New Guinea. Proc Natl Acad Sci U S A
1999;96:139737.
39. Chaudhuri A, Polyakova J, Zbrzezna V, Pogo AO. The
coding sequence of Duffy blood group gene in humans
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expression in nonerythroid tissues in Duffy-negative
individuals. Blood 1995;85:61521.
40. Rot A, von Andrian UH. Chemokines in innate and
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immune cells. Annu Rev Immunol 2004;22:891928.
41. Horuk R, Chitnis CE, Darbonne WC, et al. A receptor
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42. Pruenster M, Rot A. Throwing light on DARC. Biochem
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43. Darbonne WC, Rice GC, Mohler MA. Red blood cells
are a sink for interleukin 8, a leukocyte chemotaxin. J
Clin Invest 1991;88:13629.
44. Liu XH, Hadley TJ, Xu L, Peiper SC, Ray PE. Up-regulation
of Duffy antigen receptor expression in children with
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45. Akalin E, Neylan JF. The influence of Duffy blood
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Transplantation 2003;75:1496500.
46. Mange KC, Prak EL, Kamoun M, et al. Duffy antigen
receptor and genetic susceptibility of African Americans to acute rejection and delayed function. Kidney Int
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47. Lerut E, Van Damme B, Noizat-Pirenne F, et al. Duffy


and Kidd blood group antigens: minor histocompatibility antigens involved in renal allograft rejection? Transfusion 2007;47:2840.
48. Miller LH, Mason SJ, Clyde DF, McGinniss MH. The
resistance factor to Plasmodium vivax in blacks. The
Duffy-blood-group genotype, FyFy. N Engl J Med
1976;295:3024.
49. King CL, Michon P, Shakri AR, et al. Naturally acquired Duffy-binding protein-specific binding inhibitory antibodies confer protection from blood-stage
Plasmodium vivax infection. Proc Natl Acad Sci U S A
2008;105:83638.
50. Langhi DM Jr, Bordin JO. Duffy blood group and malaria. Hematology 2006;11:38998.
51. Goodrick MJ, Hadley AG, Poole G. Haemolytic disease
of the fetus and newborn due to anti-Fy(a) and the potential clinical value of Duffy genotyping in pregnancies
at risk. Transfus Med 1997;7:3014.
52. Westhoff CM, Sloan SR. Molecular genotyping in transfusion medicine. Clin Chem 2008;54:194850.
53. Castilho L. The value of DNA analysis for antigens in the Duffy blood group system. Transfusion
2007;47(Suppl):28S31S.
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Geralyn M. Meny, MD, Medical Director, American Red
Cross, Penn-Jersey Region, 700 Spring Garden Street,
Philadelphia, PA 19123.

Notice to Readers
Immunohematology, Journal of Blood Group
Serology and Education, is printed on acid-free
paper.

56

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Original Report

RHCE*ceAR encodes a partial c (RH4) antigen


C. Halter Hipsky, C. Lomas-Francis, A. Fuchisawa, and M.E. Reid
The Rh blood group system is highly complex both in the number of discrete antigens and in the existence of partial antigens,
especially D and e. Recently, several partial c antigens have
been reported. Here we report findings on an African American man with sickle cell disease whose RBCs typed C+c+ and
whose plasma contained anti-c. Hemagglutination tests, DNA
extraction, PCR-RFLP, reticulocyte RNA isolation, RT-PCR
cDNA analyses, cloning, and sequencing were performed by
standard procedures. RBCs from the patient typed C+c+ but
his plasma contained alloanti-c. DNA analyses showed the
presence of RHCE*Ce in trans to RHCE*ceAR with RHD*D
and RHD*Weak D Type 4.2.2. The amino acid changes on
RhceAR are such that a C+c+ patient made alloanti-c. This
case shows that RhceAR carries a partial c antigen and illustrates the value of DNA testing as an adjunct to hemagglutination to aid in antibody identification in unusual cases.
Immunohematology 2010;26:5759.
Key Words: blood groups, Rh blood group system, blood transfusion, partial antigen

he Rh blood group system is the most complex of the


30 human blood group systems.1,2 This is attributable
not only to the 50 discrete antigens3 but also to the
fact that some of the antigens, notably D, C, and e, have numerous altered forms, the so-called partial antigens.4 Partial c antigens have also been described. The first example
of alloanti-c in a c+ (presumed phenotype R1r) person was
reported in 1982.5 Anti-Rh26, which can appear as antic, has been made by an Rh26, c person6 and also by an
RH26, c+ person.7 Molecular studies revealed that Rh26
is antithetical to the low-prevalence antigen LOCR, and serologic studies have shown that the LOCR+ phenotype encodes altered (weakened) expression of c.8 Recently, it has
been shown that RHCE*ceS(340) and RHCE*(C)ceS each
encode a partial c antigen.9,10 Each of these alleles encodes a
different haplotype, and the alloanti-c may not be of identical specificity.
One of a growing number of RHCE*ce alleles that encode
an Rhce protein with an altered c antigen is RHCE*ceAR.
RHCE*ceAR has six nucleotide changes (48G>C, 712A>G,
733C>G, 787A>G, 800T>A, and 916A>G), which predict the
amino acid changes of Trp16Cys, Met238Val, Leu245Val,
Arg263Gly, Met267Lys, and Ile306Val, respectively.11 The
RHCE*ceAR allele encodes an altered e, a weak V, but no
Rh18 or hrS.12 In this article, we describe serologic and DNA
testing on blood from a C+c+ African American patient
whose plasma contains alloanti-c, thereby revealing that
RHCE*ceAR encodes a partial c antigen. We published this
finding in an abstract,13 and while this manuscript was in

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

preparation, a report by Peyrard and coworkers14 appeared


and thus there are two such cases.
Materials and Methods
Blood samples from a 17-year-old multi-transfused African American man with sickle cell disease were analyzed.
Hemagglutination
Reagents were from our libraries and obtained from
numerous colleagues and commercial sources. Hemagglutination was performed in test tubes using the method best
suited to the antibody being tested. Eluates were prepared
using Gamma Elu-Kit II (Gamma/Immucor, Norcross,
GA).
DNA and RNA Isolation, RT-PCR, Sequencing, and
Cloning
Genomic DNA was prepared from 200 L of the buffy
coat layer of peripheral blood using a DNA extraction kit
(QIAamp DNA Blood Mini Kit, Qiagen, Valencia, CA). RNA
was isolated from the reticulocytes (TriZol and PureLink
Micro-to-Midi Total RNA Purification System, Invitrogen,
Carlsbad, CA). Reverse transcription was carried out with
gene-specific RHD and RHCE primers listed in Table 1
and Superscript III, according to manufacturers instructions (Supercript III First Strand Synthesis SuperMix, Invitrogen). PCR amplification was carried out with primers
cRHx1F and cRHx5R to amplify exons 14; and cRHx4F and
cRHx10R to amplify exons 510 on RHD (RefSeq accession
NM_016124) and RHCE (RefSeq accession NM_020485)
cDNA using HotStarTaq Master Mix Kit (Qiagen). PCR amplicons were checked for purity on agarose gels, cleaned
using ExoSAP-IT (USB Corporation, Cleveland, OH) according to manufacturers instructions and directly sequenced by GeneWiz Inc. (South Plainfield, NJ). Cloning
reactions were carried out and sequenced by GeneWiz Inc.
Sequences were aligned, and protein sequence comparisons
were performed using Sequencher v4.8 (GeneCodes, Ann
Arbor, MI). The complete sequences of RHCE and RHD
were analyzed using gene-specific cDNA direct sequencing,
and to verify the results and determine which alleles carry
which alterations, all RT-PCR products of RHCE and RHD
were also cloned and sequenced. The sequence of RHD
exon 7 was determined by amplifying and sequencing exon
7 individually using genomic DNA as described previously.
To verify the RHCE*ceAR nucleotide change 48G>C that
does not always sequence well owing to its early position in
exon 1, PCR-RFLP was conducted on genomic DNA.

57

C. Halter Hipsky et al.

Table 1. Sequence and location of primers


Primer
name

Primer sequence (53)

Location

cDx10R

gtattctacagtgcataataaatggtg

Exon 10

cCEx10R

ctgtctctgaccttgtttcattatac

Exon 10

cRHx1F

agctctaagtacccgcggtctgtcc

Exon 1

cRHx5R

tggccagaacatccacaagaagag

Exon 5

cRHx4F

acgatacccagtttgtctgccatg

Exon 4

cRHx10R

tgaacaggccttgtttttcttggatgc

Exon 10

Results
Hemagglutination

The patients RBCs typed as group B, D+C+Ec+e+,
and his serum contained anti-c. His RBCs were agglutinated
by 12 commercial anti-c reagents (reagents included monoclonal and polyclonal antibodies) to the same strength as
control RBCs expressing a single dose of c antigen. As this
was a surprising result given that he had made anti-c, we
performed DNA analyses.
RH cDNA Sequence Analysis

Collectively, the results of DNA analyses showed the
presence of the following genes: RHD*D, RHD*Weak D
Type 4.2.2, RHCE*Ce, and RHCE*ceAR. The weak D Type
4.2.2 allele is the same as the RHD*DAR allele, except it
harbors a 744C>T and a 957G>A nucleotide change.15 It is
likely that the two haplotypes in this patient are RHD*D/
RHCE*Ce and RHD*Weak D Type 4.2.2/RHCE*ceAR.
Discussion

We report findings on an African American with sickle
cell disease who had been transfused on numerous occasions. His RBCs typed C+c+, and his serum contained antic reactive by the IAT. This study reveals that the amino acid
changes on RhceAR (Trp16Cys, Met238Val, Leu245Val,
Arg263Gly, Met267Lys, and Ile306Val) are such that a
C+c+ patient can make alloanti-c. Thus, ceAR carries a partial c antigen. The strong reactivity of anti-c reagents with
the patients RBCs that express Ce/ceAR and the absence of
a known low-prevalence antigen on RBCs expressing ceAR
preclude detection of the altered c antigen associated with
ceAR.

This case shows the value of DNA testing as an adjunct
to hemagglutination to aid in antibody identification in unusual cases. After we published our findings in a preliminary form13 and while this manuscript was in preparation,
Peyrard and coworkers reported a case of anti-c in a person
with the C+/ceAR phenotype.14 Thus, there are two such
published cases. The clinical relevance of the alloanti-c in
this latter case is unknown, because after it was identified, the patient received c RBC components. Interestingly, to date, the majority of partial c antigens have been in
persons of African or Hispanic ancestry.

58

Acknowledgments

We thank Robert Ratner for help in preparing this
manuscript. This study was supported in part by NIH grant
HL091030.
References
1. Reid ME, Lomas-Francis C. Blood group antigen factsbook. 2nd ed. San Diego: Academic Press, 2004.
2. Westhoff CM. The structure and function of the Rh antigen complex. Semin Hematol 2007;44:4250.
3. Daniels G, Castilho L, Flegel WA, et al. International
Society of Blood Transfusion Committee on Terminology for Red Cell Surface Antigens: Macao report. Vox
Sang 2009;96:1536.
4. Issitt PD, Anstee DJ. Applied blood group serology. 4th
ed. Durham, NC: Montgomery Scientific Publications,
1998.
5. Moulds JJ, Case J, Anderson TD, Cooper ES. The first
example of allo-anti-c produced by a c-positive individual. In: Recent Advances in Haematology, Immunology
and Blood Transfusion: Proceedings of the Plenary Sessions of the Joint Meeting of the 19th Congress of the
International Society of Haematology and the 17th Congress of the International Society of Blood Transfusion,
Budapest, August 1982. John Wiley & Sons, 1983.
6. Huestis DW, Catino ML, Busch S. A New Rh antibody
(anti-Rh 26) which detects a factor usually accompanying hr. Transfusion 1964;4:41418.
7. Faas BHW, Ligthart PC, Lomas-Francis C, et al. Involvement of Gly96 in the formation of the Rh26 epitope.
Transfusion 1997;37:112330.
8. Coghlan G, Moulds M, Nylen E, Zelinski T. Molecular basis of the LOCR (Rh55) antigen. Transfusion
2006;46:168992.
9. Ong J, Walker PS, Schmulbach E, et al. Alloanti-c in a cpositive, JAL-positive patient. Vox Sang 2009;96:240
3.
10. Pham BN, Peyrard T, Juszczak G, et al. Alloanti-c (RH4)
revealing that the (C)ce s haplotype encodes a partial c
antigen. Transfusion 2009;49:132934.
11. Hemker MB, Ligthart PC, Berger L, et al. DAR, a new
RhD variant involving exons 4, 5, and 7, often in linkage with ceAR, a new Rhce variant frequently found in
African blacks. Blood 1999;94:433742.
12. Noizat-Pirenne F, Lee K, Le Pennec P-Y, et al. Rare
RHCE phenotypes in black individuals of Afro-Caribbean
origin: Identification and transfusion safety. Blood
2002;100:422331.
13. Halter Hipsky C, Lomas-Francis C, Fuchisawa A,
et al. RHCE*ceCF and RHCE*ceAR each encode
a partial c (RH4) antigen (abstract). Transfusion
2009;49(Suppl):138A9A.

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

RHCE*ceAR encodes a partial c


14. Peyrard T, Pham BN, Poupel S, et al. Alloanti-c/ce in a
c+ceAR/Ce patient suggests that the rare RHCE*ceAR
allele (ceAR) encodes a partial c antigen. Transfusion
2009;49:240611.
15. Flegel WA, von Zabern I, Doescher A, et al. D variants
at the RhD vestibule in the weak D type 4 and Eurasian
D clusters. Transfusion 2009;49:105969.
Marion E. Reid, PhD (corresponding author), Director,
Laboratory of Immunohematology, and Head, Laboratory of Immunochemistry, and Christine Halter Hipsky,
MS, Manager, Laboratory of Immunochemistry, New
York Blood Center, 310 East 67th Street, New York, NY
10065; Christine Lomas-Francis, MSc, Technical Director, and Akiko Fuchisawa, MSc, Immunohematologist,
Laboratory of Immunohematology, New York Blood Center, Long Island City, NY.

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IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

59

Review

The Gerbich blood group system: a review


P.S. Walker and M.E. Reid
Antigens in the Gerbich blood group system are expressed on
glycophorin C (GPC) and glycophorin D (GPD), which are both
encoded by a single gene, GYPC. The GYPC gene is located on
the long arm of chromosome 2, and Gerbich antigens are inherited as autosomal dominant traits. There are 11 antigens in
the Gerbich blood group system, six of high prevalence (Ge2,
Ge3, Ge4, GEPL [Ge10*], GEAT [Ge11*], GETI [Ge12*]) and
five of low prevalence (Wb [Ge5], Lsa [Ge6], Ana [Ge7], Dha
[Ge8], GEIS [Ge9]). GPC and GPD interact with protein 4.1R,
contributing stability to the RBC membrane. Reduced levels of GPC and GPD are associated with hereditary elliptocytosis, and Gerbich antigens act as receptors for the malarial
parasite Plasmodium falciparum. Anti-Ge2 and anti-Ge3 have
caused hemolytic transfusion reactions, and anti-Ge3 has produced hemolytic disease of the fetus and newborn (HDFN).
Immunohematology 2010;26:6065.
Key Words: blood group, Gerbich, glycophorin, GPC

History
In 1960, Rosenfield et al.1 described the first examples
of anti-Gerbich in the sera of three women, including Mrs.
Gerbich, after whom the blood group system is named. A
year later, Cleghorn2 and Barnes and Lewis3 reported on a
Turkish Cypriot woman, Mrs. Yus, whose RBCs were compatible with two of the original three sera but were incompatible with serum from Mrs. Gerbich. In 1970, Booth et
al.4 reported on the prevalence of the Gerbich (GE) blood
group in Melanesians, and in 1972, Booth5 reported that
certain Ge+ individuals demonstrated an antibody that was
compatible with RBCs expressing the Gerbich or the Yus
phenotype, but was incompatible with up to 15 percent of
Ge+ Melanesians.
After Zelinski et al.6 demonstrated that Gerbich is genetically discrete from all other existing systems, the Gerbich antigen collection (ISBT Collection 201) was upgraded
to the GE blood group system (ISBT system symbol GE and
number 020) by the ISBT Working Party on Terminology
for Red Cell Surface Antigens.7
Biochemistry
In 1984, Anstee et al.8 reported that individuals
who lack Gerbich blood group antigens have alterations
in their erythrocyte membrane sialoglycoproteins. In
1984, these proteins were called -syaloglycoprotein and
-syaloglycoprotein; however, the current terminology is
glycophorin C (GPC) and glycophorin D (GPD). Gerbich
antigens are found on GPC and GPD. These sialic acidrich

glycoproteins are also known as CD236R, and they attach


to the RBC membrane through an interaction with protein
4.1R and p55. GPC and GPD contain three domains: an extracellular NH2 domain, a transmembrane domain, and an
intracellular or cytoplasmic COOH domain (Figure 1). GPC
and GPD are encoded by the same gene, GYPC. When the
first AUG initiation codon is used, GPC is encoded, whereas
when the second AUG is used, GPD is encoded. Thus, GPD
is a shorter version of GPC, and the amino acids in GPD
are identical to those found in GPC but lacking the first 21
amino acids at the N-terminal of GPC.9,10
1 NH2
Wb/Wb+
Asn8Ser
Dh(a)/Dh(a+)
Leu14Phe
GEAT+/GEAT
Asp19Val
GETI+/GETI
Thr27Ile
GEIS/GEIS+
Thr32Asn
GELP/GELP+
Pro45Leu

Ge4

Ge2

1NH2
An(a)/An(a+)
Ala2Ser
GETI+/GETI
Thr6Ile
GEIS/GEIS+
Thr11Asn

Ge3

Ge3

Trypsin

48

GELP+/GELP
Pro24Leu
27
46

57

RBC
Lipid
Bilayer
82

71

128 COOH

GPC

107 COOH

GPD

Fig. 1. Molecules (glycophorin C [GPC] and glycophorin D [GPD])


showing location of various Gerbich antigens. The stick figures give
the amino acid residue numbers defining the extracellular, transmembrane, and intracellular domains of GPC and GPD. Also shown is the
trypsin cleavage site and location of all antigens except Lsa, which is
the result of amino acids encoded by the duplication of exon 3.

*Nomenclature pending approval by the ISBT Working Party on Terminology for Red Cell Surface Antigens.

60

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Gerbich blood group system


Certain Gerbich antigens (Ge4, Wb, Dha, GEAT) are
only expressed on GPC, two (Ge2, Ana) are only expressed
on GPD, and others (Ge3, Lsa, GEIS, GEPL, GETI) are expressed on both GPC and GPD. Despite the fact that GPC
possesses all of the amino acids that are found on GPD, the
likely explanation for why some antibodies only react with
GPD is that the antibodies require a conformational epitope
that is present at the amino terminus of GPD but absent in
the subterminal amino acid sequence of GPC. Some examples of anti-Ge2 do not react with RBCs after the acetylation
of membrane proteins with acetic anhydride, suggesting
that a free amino group is involved in the epitope detected
by these antibodies.11 A diagram showing the trypsin cleavage site and location of Ge2, Ge3, and Ge4 antigens is given
in Figure 1.

In 1990, Reid et al.12 reported that GPC plays a functionally important role in maintaining erythrocyte shape and
regulating the membrane properties through its interaction
with protein 4.1R. In 1993, Alloisio et al.13 showed that p55,
a peripheral membrane protein in human erythrocytes, is
associated in precise proportions with the protein 4.1R
GPC complex, linking the cytoskeleton and the membrane.
The absence of GPC and GPD is associated with hereditary
elliptocytosis, which is described later in this discussion.

Table 1. Summary of nucleotide and amino acid changes in Ge phenotypes

Inheritance and Molecular Genetics



In 1986, Colin et al.14 cloned the gene GYPC, and Mattei
et al.15 determined that GYPC is located on chromosome 2,
in the region of q14q21. The GYPC gene consists of 13.5
kilobase pairs (kbp) of gDNA, comprising four exons. Exons 2 and 3 are homologous, with less than 5 percent nucleotide divergence. This can lead to unequal crossing over
during meiosis and loss (outsplicing) of exon 2 or exon 3. In
1987 Le Van Kim et al.16 reported that a deletion of approximately 3 kb in the GYPC gene is associated with the Gerbich
blood group deficiency types Yus (GE:2,3) and Gerbich
(GE:2,3). In 1989, High et al.17 reported that the absence
of exon 2 results in the Yus phenotype, whereas the absence
of exon 3 results in the Gerbich phenotype. The Gerbich
phenotype has also been produced by a nucleotide change
and deletion of exon 3 of the GYPC.18 The Leach phenotype
(GE:2,3,4) may be produced by two different mechanisms. The PL type of the Leach phenotype is caused by
a deletion of exons 3 and 4, whereas the LN type is a consequence of a 131G>T nucleotide change (134delC in exon
3; Trp44Leu) that leads to a frame shift and a premature
stop codon. Other Ge antigens are a consequence of nucleotide changes in GYPC (Table 1).19 The products of the Ge
alleles are inherited in an autosomal codominant manner.20
A gene map is shown in Figure 2.
Fig. 2. Glycophorin C (GYPC) gene map. GYPC is
composed of four exons and three introns that are
distributed over 13.5 kb of genomic DNA. Exons are
the regions of the gene sequence that code for the
amino acids that constitute the glycoproteins, GPC
and GPD. The introns separate the exons, and they
are not encoded. Locations of the ATG (start codon)
for initiation of GPC and GPD are indicated.
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Phenotype

Traditional
name

Nucleotide
change
exon/
intron

GE:2,3,4

Yus type

del exon 2

Deletion of
amino acids,
altered GPC

Hispanic,
Israeli, and
Mediterranean
populations
(rare)

GE:2,3,4

Gerbich
type

del exon 3

Deletion of
amino acids,
altered GPC

Melanesians
(50%)
Others (rare)

GE:5

Wb+

23A>G in
exon 1

Asn8Ser in
GPC

Wales and
Australia
(few)
Others (rare)

GE:6

Ls(a+)

Duplicated
or triplicated
exon 3

Duplication,
altered GPC

Blacks (2%)
Finns (1.6%)
Others
(Rare)

GE:7

An(a+)

67G>T
in exon 2

Ala23Ser in
GPC;
Ala2Ser in
GPD

Finns (0.2%)
Others (rare)

GE:8

Dh(a+)

40C>T in
exon 1

Leu14Phe in
GPC

Original
proband
was Danish
(rare)

GE:9

GEIS+

95C>A in
exon 2

Thr32Asn in
GPC;
Thr11Asn in
GPD

Japanese
(rare)

GE:10

GEPL

134C>T in
exon 3

Pro45Leu in
GPC19
Pro24Leu in
GPD

(rare)

GE:11

GEAT

56A>T in
exon 2

Asp19Val in
GPC19

(rare)

GE:12

GETI

80C>T in
exon 2

Thr27Ile in
GPC19
Thr6Ile in
GPD

(rare)

GE:2,
3,4

Leach type
(PL)

del exons 3
and 4

GE:2,
3,4

Leach type
(LN)

131G>T;
134delC in
exon 3

Amino acid
change

Ethnicity
(occurrence)

Null
phenotype
(rare)
Trp44Leu;
45fs; 55Stop

(rare)

GPC = glycophorin C; GPD = glycophorin D.


the altered GPC does not express Ana.

Exon 1

ATG
for GPC

6.2 kb

Exon 2

ATG
for GPD

3.4 kb

Exon 3

1.8 kb

100 bp

Exon 4

724 bp

STOP

61

P.S. Walker and M.E. Reid

Gerbich Antigens

There are six high-prevalence antigens and five lowprevalence antigens in the Gerbich blood group system. As
examples of anti-Ge1 are no longer available, the Ge1 antigen was declared to be obsolete by the ISBT working party
for terminology of red cell surface antigens.

loss of the N-glycan and the gain of an O-glycan.24 Lsa (Ge6)


(Lewis)25 results from a novel amino sequence encoded by
a duplication or triplication of exon 3 of GYPC. The allele
with a duplication of exon 3 is the reciprocal product of the
altered GYPC (GYPC.Ge) that lacks exon 3 and encodes the
Gerbich phenotype.

High-Prevalence Antigens

Ge2 is absent from RBCs with the Yus, Gerbich, or
Leach phenotype. Ge2 is located at the NH2 terminal 19
amino acids of GPD and is not expressed on GPC. Ge3 is
absent from RBCs with the Gerbich or Leach phenotype.
Ge3 is expressed on both GPC and GPD within their extracellular portion close to the lipid bilayer. Ge4 is absent only
from RBCs with the Leach phenotype, which is the null phenotype in the Gerbich blood group system. Ge4 is located
within the NH2 terminal 19 amino acids of GPC (Figure 1;
Table 2).

The Ge-negative phenotypes, which can be difficult
to differentiate by hemagglutination with polyclonal antibodies, are readily distinguished by testing trypsin-treated
RBCs with monoclonal anti-Ge4. The reaction patterns are
shown in Table 3.

Three other high-prevalence Ge antigens, GEPL
(Ge10*), GEAT (Ge11*), and GETI (Ge12*), are each a consequence of a nucleotide change in GYPC (Table 1).19

Altered Antigen Expression



In protein 4.1Rdeficient RBCs, Gerbich antigens are
expressed weakly. As GPC and GPD interact with protein
4.1R, an absence of this protein causes a reduced level of
GPC and GPD in the RBC membrane.12 The weakening of
Ge2 and Ge3 antigens can be such that, under certain testing conditions, they can appear to be absent.

Gerbich-negative RBCs may show a weakened expression of certain other blood group antigens, notably Kell and
Vel. Nine of 11 GE:2,3 samples showed different degrees
of weakening of Kell system antigens, whereas none of six
GE:2,3 samples showed Kell depression.26 Similarly, 3 of
14 examples of anti-Vel failed to react with four GE:2,3,4
samples, but they did react with one example each of GE:
2,3,4 and GE:2,3,4 RBC samples.27

Table 2. Gerbich-negative phenotypes


Traditional
phenotype
name

ISBT phenotype name

Antibodies

Yus

GE:2,3,4

Anti-Ge2

GE:2,3,4,
GE:23,4, and
GE:2,3,4

Gerbich

GE:2,3,4

Anti-Ge3 or antiGe2

GE:2,3,4 and
GE:2,3,4
(if anti-Ge2 then
compatible with
GE:2,3,4)

Leach

GE:2,3,4

Anti-Ge4, antiGe3, or anti-Ge2

Compatible
with

GE:2,3,4
only

Table 3. Differentiation of Ge-negative phenotypes using monoclonal


anti-Ge4
RBCs

Normal

Yus

Gerbich

Leach

Untreated

4+

02+

02+

Trypsin-treated

4+

Low-Prevalence Antigens

Wb (Ge5)(Webb),21 Ana (Ge7)(Ahonen),11 Dha (Ge8)
(Duch),22 and GEIS (Ge9)23 each result from a nucleotide
change in GYPC (Table 1). The Wb (Ge5) antigen results
from the substitution Asn8Ser near the NH2 terminus of
GPC. This substitution interrupts the consensus sequence
for N-glycosylation (Asn-X-Ser/Thr), which results in a
62

Antibodies to Gerbich Antigens


Anti-Ge2

Anti-Ge2 may be immune or naturally occurring and
reacts with an antigen on GPD. Anti-Ge2 is usually an IgG
antibody that reacts by the IAT. Some examples of anti-Ge2
have been complement binding and hemolytic. Treatment
of RBCs with papain or ficin results in the loss of reactivity
with anti-Ge2; however, when RBCs treated with 200 mM
DTT are tested with anti-Ge2, variable results are obtained.
Individuals with Yus, Gerbich, or Leach phenotypes can
make anti-Ge2 (Table 2).28 The clinical significance of antiGe2 is discussed below.
Anti-Ge3

Anti-Ge3 reacts with an antigen on both GPC and GPD.
Anti-Ge3 is usually an IgG antibody that reacts by the IAT;
however, some IgM forms have been reported. Many examples of anti-Ge3 bind complement and are hemolytic.
Anti-Ge3 reacts with RBCs that were treated with papain or
ficin and 200 mM DTT. Individuals with Gerbich or Leach
phenotypes can make anti-Ge3 (Table 2).28 The clinical significance of anti-Ge3 is discussed later.
Anti-Ge4

Alloanti-Ge4 is very rare; only one human example has
been described That antibody was IgG, and it reacted by the
IAT.29 Numerous examples of monoclonal antibodies with
Ge4 specificity have been produced.30,31 Treatment of RBCs
with papain or ficin results in the loss of reactivity with antiGe4, however, treatment of RBCs with 200 mM DTT does
not affect their reactivity with anti-Ge4.28 Individuals with
Leach phenotype can make anti-Ge4 (Table 2).28 There is no
information about the clinical significance of anti-Ge4.
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Gerbich blood group system

Antibodies to Low-Prevalence Antigens


Wb(Ge5), Lsa(Ge6), Ana(Ge7), Dha(Ge8), GEIS (Ge9)

These antibodies may be IgM or IgG, and they may be
naturally occurring. They react at room temperature and
by the IAT, and none are complement-binding. Treatment
of antigen-positive RBCs with papain or ficin results in the
loss of reactivity with these antibodies; however, the antigens are resistant to treatment with 200 mM DTT.28 There
are no reports of clinically significant transfusion reactions
or HDFN associated with these antibodies.
Clinical Significance
Transfusion Reactions

Some examples of anti-Ge2 and anti-Ge3 have caused
moderate transfusion reactionsboth immediate and delayed; however, other examples have failed to produce
shortened RBC survival when antigen-positive incompatible units were transfused.3234 Pearson et al.35 reported a
case of alloanti-Ge in which there were discrepant results
between an in vivo chromium-51 (51Cr) survival study and
an in vitro monocyte assay. In that case, the in vivo 51Cr survival study yielded zero survival of Gerbich-positive cells
after 24 hours; however, a monocyte assay showed less
than 1 percent lysis of Gerbich-positive cells. The clinical
significance in this case was not determined because only
Gerbich-negative blood was transfused during surgery.
HDFN

Anti-Ge2 has been associated with a positive DAT in infants with GE:2 RBCs; however, no cases of clinical HDFN
have been reported. By contrast, anti-Ge3 appears to be capable of causing severe HDFN. An interesting recent publication shows that the mechanism for anemia, and possibly
for thrombocytopenia, in HDFN caused by anti-Ge3 may
be attributed to interference with the erythropoietin signaling cascade.36 Similar to the mechanism of erythroid suppression described in HDFN caused by anti-K,37 anti-Ge3
has been associated with antibody-dependent hemolysis, as
well as inhibition of erythroid progenitor cell growth in the
infant. In these cases, the affected infants may require initial treatment at delivery, followed by monitoring for signs
of anemia for several weeks after birth.38,39
Autoimmune Hemolytic Anemia

Several cases of autoimmune hemolytic anemia (AIHA)
with anti-Ge specificity have been reported. In two cases,
the course of the AIHA was as expected, i.e., the patients
typed Ge+, their serum demonstrated anti-Ge antibodies,
their DATs were positive, and eluates from the autologous
RBCs demonstrated Ge-like antibodies.40,41

In one case, the patient typed Ge+ and the serum was
nonreactive, but an eluate from the patients RBCs demonstrated anti-Ge specificity.42 This is the first report of IgMmediated warm AIHA associated with autoanti-Ge. In two
other cases, the patients typed Ge+ and their serum demonstrated anti-Ge, but their serum failed to react with the
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

autologous RBCs (DAT-negative).43,44 However, in both of


these cases, eluates from the patients RBCs demonstrated
an antibody with Ge specificity. Without the eluate results,
these cases could have been confused with alloanti-Ge. One
possible explanation for these findings could be a weakening
of the Gerbich antigens during the course of the AIHA. In
cases of severe life-threatening hemolysis, it might be advisable to select Ge-negative units for transfusion.
Hereditary Elliptocytosis

Gerbich antigens interact with protein 4.1R, which contributes to the stability of the RBC membrane.12,45,46 In 1986,
Daniels et al.31 described a family with hereditary elliptocytosis that was associated with the Leach phenotype. In 1991,
Telen et al.47 further explained the molecular basis for the
elliptocytosis as the deficiency of GPC and GPD that is associated with the Leach phenotype. Patients with hereditary
elliptocytosis rarely require transfusions. If such a patient
requires transfusions for other reasons (e.g., surgery) and
the patient demonstrates alloanti-Ge, it might be prudent
to select Gerbich-negative units for transfusion, if such rare
blood is available.
Malaria

In northern Papua New Guinea, where malaria is endemic, Serjeantson 48 reported in 1989 that Gerbichnegative Melanesians appear to have a selective advantage
for avoiding infections with Plasmodium falciparum and
Plasmodium vivax. Subsequent studies confirmed that P.
falciparum binds to RBCs through a receptor on wild-type
GPC, which is missing on Gerbich-negative cells that express a truncated form of GPC.4951
Summary

The Gerbich blood group system is composed of six
high-prevalence antigens, which are expressed on GPC,
GPD, or both. GPC and GPD are encoded by a single gene,
GYPC, which is located on the long arm of chromosome 2.
By interacting with protein 4.1R, GPC and GPD contribute
stability to the RBC membrane, and a deficiency in these
proteins has been associated with hereditary elliptocytosis.
Also, Gerbich antigens apparently act as receptors for P.
falciparum malaria. Certain Gerbich antibodies are clinically significant, e.g., anti-Ge2 and anti-Ge3 have caused
hemolytic transfusion reactions, and anti-Ge3 has produced
HDFN.
Acknowledgments

The authors thank Robert Ratner for help in preparing
the manuscript and figures.
References
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2. Cleghorn TE. The occurrence of certain rare blood


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8. Anstee DJ, Ridgwell K, Tanner MJ, Daniels GL, Parsons
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13. Alloisio N, Dalla Venezia N, Rana A, et al. Evidence that
red blood cell protein p55 may participate in the
skeleton-membrane linkage that involves protein 4.1
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14. Colin Y, Rahuel C, London J, et al. Isolation of cDNA
clones and complete amino acid sequence of human
erythrocyte glycophorin C. J Biol Chem 1986;261:229
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15. Mattei MG, Colin Y, Le Van Kim C, Mattei JF, Cartron
JP. Localization of the gene for human erythrocyte
glycophorin C to chromosome 2, q14-q21. Hum Genet
1986;74:4202.

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16. Le Van Kim C, Colin Y, Blanchard D, Dahr W, London


J, Cartron JP. Gerbich blood group deficiency of the
Ge:1,2,3 and Ge:1,2,3 types. Immunochemical
study and genomic analysis with cDNA probes. Eur J
Biochem 1987;165:5719.
17. High S, Tanner MJ, Macdonald EB, Anstee DJ. Rearrangements of the red-cell membrane glycophorin
C (sialoglycoprotein beta) gene. A further study of
alterations in the glycophorin C gene. Biochem J
1989;262:4754.
18. King M-J, Kosanke J, Reid ME, et al. Co-presence of a
point mutation and a deletion of exon 3 in the glycophorin
C gene and concomitant production of a Gerbich-related
antibody. Transfusion 1997;37:102734.
19. Poole J, Tilley L, Hudler P, et al. Novel mutations in
GYPC giving rise to lack of Ge epitopes and anti-Ge production (abstract). Vox Sang 2008;95(Suppl 1):181.
20. Reid ME, Sullivan C, Taylor M, Anstee DJ. Inheritance
of human-erythrocyte Gerbich blood group antigens.
Am J Hum Genet 1987;41:111723.
21. Bloomfield L, Rowe GP, Green C. The Webb (Wb) antigen in South Wales donors. Hum Hered 1986;36:352
6.
22. King MJ, Avent ND, Mallinson G, Reid ME. Point mutation in the glycophorin C gene results in the expression
of the blood group antigen Dha. Vox Sang 1992;63:56
8.
23. Yabe R, Uchikawa M, Tuneyama H, et al. Is: a new Gerbich blood group antigen located on the GPC and GPD
(abstract). Vox Sang 2004;87(Suppl 3):79.
24. Chang S, Reid ME, Conboy J, Kan YW, Mohandas N.
Molecular characterization of erythrocyte glycophorin
C variants. Blood 1991;77:6448.
25. Reid ME, Mawby W, King M-J, Sistonen P. Duplication
of exon 3 in the glycoprotein C gene gives rise to the Lsa
blood group antigen. Transfusion 1994;34:9669.
26. Daniels GL. Studies on Gerbich negative phenotypes and Gerbich antibodies (abstract). Transfusion
1982;22:405.
27. Issitt P, Combs M, Carawan H, et al. Phenotypic association between Ge and Vel (abstract). Transfusion
1994;34(Suppl):60S.
28. Reid ME, Lomas-Francis C. Blood group antigens and
antibodies: a guide to clinical relevance and technical
tips. New York, NY: Star Bright Books, 2007.
29. McShane K, Chung A. A novel human alloantibody in
the Gerbich system. Vox Sang 1989;57:2059.
30. Anstee DJ, Parsons SF, Ridgwell K, et al. Two individuals with elliptocytic red cells apparently lack three minor erythrocyte membrane sialoglycoproteins. Biochem
J 1984;218:61519.

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Gerbich blood group system

31. Daniels G, Shaw MA, Judson PA, et al. A family demonstrating inheritance of the Leach phenotype: a Gerbichnegative phenotype associated with elliptocytosis. Vox
Sang 1986;50:11721.
32. Mochizuki T, Tauxe WN, Ramsey G. In vivo crossmatch by chromium-51 urinary excretion from labeled erythrocytes: a case of anti-Gerbich. J Nucl Med
1990;31:20424.
33. Hildebrandt M, Hell A, Etzel F, Genth R, Salama A.
Determination and successful transfusion of antiGerbich-positive red blood cells in a patient with a
strongly reactive anti-Gerbich antibody. Infusionsther
Transfusionsmed 2000;27:1546.
34. Selleng S, Selleng K, Zawadzinski C, Wollert HG, Yrek
S, Greinacher A. Management of emergency cardiac
surgery in a patient with alloanti-Ge2. Transfus Med
2009;19:502.
35. Pearson HA, Richards VL, Wylie BR, et al. Assessment
of clinical significance of anti-Ge in an untransfused
man. Transfusion 1991;31:2579.
36. Micieli JA, Wang D, Denomme GA. Anti-glycophorin
C induces mitochondrial membrane depolarization
and a loss of extracellular regulated kinase 1/2 protein
kinase activity that is prevented by pretreatment with
cytochalasin D: implications for hemolytic disease of
the fetus and newborn caused by anti-Ge3. Transfusion
2010;50:1761-5.
37. Vaughan JI, Warwick R, Letsky E, Nicolini U, Rodeck
CH, Fisk NM. Erythropoietic suppression in fetal anemia because of Kell alloimmunization. Am J Obstet Gynecol 1994;171:24752.
38. Arndt PA, Garratty G, Daniels G, et al. Late onset neonatal
anaemia due to maternal anti-Ge: possible association
with destruction of eythroid progenitors. Transfus Med
2005;15:12532.
39. Blackall DP, Pesek GD, Montgomery MM, et al. Hemolytic disease of the fetus and newborn due to anti-Ge3:
combined antibody-dependent hemolysis and erythroid precursor cell growth inhibition. Am J Perinatol
2008;25:5415.
40. Reynolds MV, Vengelen-Tyler V, Morel PA. Autoimmune hemolytic anemia associated with autoanti-Ge.
Vox Sang 1981;41:617.
41. Shulman IA, Vengelen-Tyler V, Thompson JC, Nelson
JM, Chen DC. Autoanti-Ge associated with severe autoimmune hemolytic anemia. Vox Sang 1990;59:2324.
42. Sererat T, Veidt D, Arndt PA, Garratty G. Warm autoimmune hemolytic anemia associated with an IgM
autoanti-Ge. Immunohematology 1998;14:269.
43. Poole J, Reid ME, Banks J, Liew YW, Addy J, Longster G. Serological and immunochemical specificity
of a human autoanti-Gerbich-like antibody. Vox Sang
1990;58:28791.
44. Gttsche B, Salama A, Mueller-Eckhardt C. Autoimmune hemolytic anemia associated with an IgA
autoanti-Gerbich. Vox Sang 1990;58:21114.
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

45. Mudad R, Telen MJ. Biologic functions of blood group


antigens. Curr Opin Hematol 1996;3:4739.
46. Daniels G. Functional aspects of red cell antigens. Blood
Rev 1999;13:1435.
47. Telen MJ, Le Van Kim C, Chung A, Cartron JP, Colin Y.
Molecular basis for elliptocytosis associated with glycophorin C and D deficiency in the Leach phenotype.
Blood 1991;78:16036.
48. Serjeantson SW. A selective advantage for the Gerbichnegative phenotype in malarious areas of Papua New
Guinea. P N G Med J 1989;32:59.
49. Patel SS, Mehlotra RK, Kastens W, Mgone CS, Kazura JW, Zimmerman PA. The association of the glycophorin C exon 3 deletion with ovalocytosis and malaria
susceptibility in the Wosera, Papua New Guinea. Blood
2001;98:348991.
50. Maier AG, Duraisingh MT, Reeder JC, et al. Plasmodium falciparum erythrocyte invasion through glycophorin C and selection for Gerbich negativity in human
populations. Nat Med 2003;9:8792.
51. Mayer DC, Jiang L, Achur RN, Kakizaki I, Gowda DC,
Miller LH. The glycophorin C N-linked glycan is a critical component of the ligand for the Plasmodium falciparum erythrocyte receptor BAEBL. Proc Natl Acad Sci
U S A 2006;103:235862.
Phyllis S. Walker, MS, MT(ASCP)SBB (corresponding author), 399 Warren Drive, San Francisco, CA 94131-1033;
and Marion E. Reid, PhD, Head, Laboratory of Immunochemistry and Director, Laboratory of Immunohematology, New York Blood Center, New York, NY.

For information concerning the National


Reference Laboratory for Blood Group
Serology, including the American Rare
Donor Program, please contact Sandra
Nance, by phone at (215) 451-4362, by fax at
(215) 451-2538, or by e-mail at snance@usa.
redcross.org

65

Original Report

Application of real-time PCR and melting


curve analysis in rapid Diego blood group
genotyping
M.C.Z. Novaretti, A.S. Ruiz, P.E. Dorlhiac-Llacer and D.A.F Chamone
The paucity of appropriate reagents for serologic typing of the
Diego blood group antigens has prompted the development of a
real-time PCR and melting curve analysis for Diego blood group
genotyping. In this study, we phenotyped 4326 donor blood
samples for Dia using semiautomated equipment. All 157 Di(a+)
samples were then genotyped by PCR using sequence-specific
primers (PCR-SSP) for DI*02 because of anti-Dib scarcity. Of
the 4326 samples, we simultaneously tested 160 samples for Dia
and Dib by serology, and for DI*01 and DI*02 by PCR-SSP and
by real-time PCR. We used the same primers for Diego genotyping by real-time PCR and PCR-SSP. Melting curve profiles
obtained using the dissociation software of the real-time PCR
apparatus enabled the discrimination of Diego alleles. Of the
total samples tested, 4169 blood donors, 96.4 percent (95%
confidence interval [CI], 95.896.9%), were homozygous for
DI*02 and 157, 3.6 percent (95% CI, 3.14.2%), were heterozygous DI*01/02. No blood donor was found to be homozygous
for DI*01 in this study. The calculated DI*01 and DI*02 allele
frequencies were 0.0181 (95% CI, 0.01730.0189) and 0.9819
(95% CI, 0.97910.9847), respectively, showing a good fit for
the Hardy-Weinberg equilibrium. There was full concordance
among Diego phenotype results and Diego genotype results by
PCR-SSP and real-time PCR. DI*01 and DI*02 allele determination with SYBR Green I and thermal cycler technology are useful
methods for Diego determination. The real-time PCR with SYBR
Green I melting temperature protocol can be used as a rapid
screening tool for DI*01 and DI*02 blood group genotyping.
Immunohematology 2010;26:6670.

on an 18-kilobase (kb) genomic DNA, maps to chromosome 17q12q21, and consists of 20 exons.10 The DI*01 and
DI*02 alleles code for the antithetical Dia and Dib antigens,
respectively.11
DI*01 and DI*02 polymorphism is determined by a
T>C nucleotide substitution at position +2561 in exon 19
of the SLC4A1 gene, changing the leucine at amino acid position 854 to a proline in the band 3 protein.12 No healthy
individual with a Diego null phenotype has been reported,
reflecting the functional importance of band 3. Although no
Di(ab) subjects have been recognized by serologic testing, Alloisio et al.13 described one individual who is homozygous for a band 3 mutation, Va1488Met (band 3 Coimbra),
that results in almost complete deficiency of band 3. At the
clinical level, Diego blood group antigens are of considerable importance in relation to their role in transfusion reactions and HDN. The Brazilian population is composed of a
highly mixed ancestry, with an incidence of 1.3 percent of
Di(a+) blood donors.14 Consequently, multiply transfused
individuals can have anti-Dia or rarely anti-Dib.1416 Furthermore, commercial anti-Dia for serologic testing is scarce,
and there is no available commercial anti-Dib for routine
use. The aim of this study was therefore to describe a DNAbased typing method that allows blood samples to be tested
for DI*01 and DI*02 using a PCR real-time method.

Key Words: blood donors, genotyping, real time, PCR, blood


groups, Diego blood group, population, gene frequency

Material and Methods


This is a prospective study performed at Fundao
Pr-Sangue/Hemocentro, So Paulo, Brazil. A total of
4326 venous blood samples from unrelated Brazilian volunteer blood donors were collected in EDTA and tested for
Dia by hemagglutination. Every Di(a+) blood sample was
then tested for Dib by PCR using sequence-specific primers
(PCR-SSP) owing to anti-Dib scarcity. We then performed
real-time PCR validation for Diego genotyping. Finally, we
performed Diego analysis in 160 of 4326 blood samples for
Dia and Dib by serologic studies, PCR-SSP, and real-time
PCR simultaneously. The results were interpreted blinded
from the serologic results.
Dia phenotyping was performed using 50 L of anti-Dia
(DiaMed AG, Cressier-sur-Morat, Switzerland) and 25 L
of a 1% RBC suspension dispensed into a microplate using
semiautomated equipment (Megaflex-TECAN, TECAN AG,
Hombrechtikon, Switzerland). After incubation for 30 minutes at 37C, the microplates were centrifuged at 468g for
15 seconds. The microplates were then washed three times

he Diego blood group system was named after identifying a new antibody, anti-Dia, which caused HDN
resulting in the death of a Venezuelan newborn in
1955.1,2 Anti-Dib was described in 1967 in two Mexicans by
Thompson et al.3 Anti-Dia and -Dib are clinically relevant.
Both have been implicated in transfusion reactions and in
HDN.46
The Diego blood group system comprises 21 antigens,
and Dia and Dib are the most clinically significant.7 Although
Dib is present in virtually all populations, Dia incidence varies substantially worldwide. It is found in 7 to 54 percent of
South American Indians, 5 to 8 percent of Asians (Chinese,
Korean, Japanese), and 14.7 percent of Mexican Americans,
whereas it is rare in Whites and Blacks (0.01%).3,8,9
Dia and Dib are carried on band 3 protein. The single
SLC4A1 gene (solute carrier family 4, anion exchanger,
member 1) controls band 3 expression. This gene extends
66

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Real-time PCR in Diego genotyping

with saline solution and centrifuged at 468g for 15 seconds.


Fifty L of antihuman globulin (AHG) serum (DiaMed Latino America, Lagoa Santa, Brazil) was added to each well;
the microplates were centrifuged at 468g for 15 seconds,
and read immediately. Dib phenotyping was performed
in gel cards (DiaMed Latino America) using anti-Dib previously identified in a patient. The donors RBCs were
washed three times in 0.9% saline solution and suspended
in LISS (ID-Diluent 2, DiaMed Latino America) to a final
0.8% suspension. In a microtube of the LISS/AHG ID card
(DiaMed Latino America), 50 L of 0.8% donor RBCs and
25 L of patients serum were dispensed and incubated
at 37C for 15 minutes in an appropriate incubator (IDIncubator 37SI, DiaMed AG). After incubation, the cards
were centrifuged for 10 minutes in an appropriate centrifuge (ID-Centrifuge 24S, DiaMed AG). After centrifugation, the cards were examined for agglutination or hemolysis according to the manufacturers instructions. Positive
and negative known control samples were included in each
batch for Diego phenotyping validation results.
DNA Extraction
Human genomic DNA was isolated from whole blood in
duplicate, using a commercial DNA extraction kit (QIAamp
DNA Blood Mini Kit, QIAGEN Science, Hilden, Germany).
DNA was extracted from 200 L of blood and eluted in 100
L of buffer according to the manufacturers recommendations. For all samples, a mean of 100 ng of DNA was obtained. DNA was stored at 20C for long-term storage.

Real-time PCR

The same two sets of primers used for DI*01 and DI*02
polymorphism detection by PCR-SSP were also used for
real-time PCR. Real-time PCR was carried out in 0.1-mL
strip tubes and Caps (Corbett Research, Mortlake, Australia) using the same primers used for the PCR-SSP method
(Table 1). Each reaction contained 7.5 L of 2x Quantitect
SYBR Green PCR Master Mix (QIAGEN Science), 0.3 M of
each forward and reverse primer, 100 ng of genomic DNA,
and nuclease-free water in a final volume of 15 L. PCR
amplifications and fluorescence detection were performed
using Rotor Gene 3000 equipment (Corbett Research, Sydney, Australia). The PCR amplification profile was a 95C
enzyme activation step (10 minutes), followed by 35 cycles
of 95C denaturation (30 seconds), 60C annealing (30 seconds), and 72C extension (90 seconds). Melting curves were
generated by monitoring the continuous decrease in fluorescence of the SYBR Green signal from 75 to 95C at the end
of each run. Data acquisition and analysis were handled by
the Rotor Gene 6 software (Corbett Research). In each run,
we included samples homozygous for DI*01 and DI*02 used
in the validation process as control samples.
Statistical Analysis

Allele frequencies were calculated by direct gene counting, and the differences were analyzed by the 2 test using
a 2 2 contingency table. All analyses were performed on
Statistica software (SAS Institute, Cary, NC).

Results
PCR-SSP
Real-time PCR Validation
All samples were genotyped in duplicate for DI*01

In the validation process of real-time PCR for DI*01 and
and DI*02 alleles by the PCR-SSP method and real-time
DI*02, we tested 62 reference samples from the Fundao
PCR simultaneously, using primers designed by Wu et al.17
Pr-Sangue, after which these samples were genotyped for
(Table 1) The F2/AR pair of primers detected the DI*01
DI*01 and DI*02 using PCR-SSP (Figure 1A) and by realallele, and the BF/R pair detected DI*02. Primers amplitime PCR (Figure 1B) on two occasions. The results were
fying a fragment of the human growth hormone (HGH)
interpreted blinded from the serologic results. We found a
gene served as an internal control.18,19 PCR-SSP was cargenotype-specific melting profile for DI*01 and DI*02, with
ried out in a final volume of 25 L containing 100 ng of
both amplifications performed in one single run. This step
purified DNA, 1.5 L of MgCl2 (1.5 mM), 1 L of dNTP mix
was critical for the optimization of our real-time PCR protocol
(0.2 mM, Invitrogen, Carlsbad, CA), 1.5 U of Taq
polymerase (Platinum Taq DNA Polymerase, InTable 1. Primers used for DI genotyping by PCR SSP and real-time PCR
vitrogen, So Paulo, Brazil), 2.5 L of Tris-HCl
Pair of
Gene
PCR
(10 mM, pH 8.3, 50 mM KCl), 0.3 M of each
Primer
Sequence (5-3)
Ref primers detect- Product
ed
(bp)
forward and reverse primer, and 0.08 M of in
ternal control. Amplifications were programmed
F2
GTGCTGGGGTGTGATAGGC
(17)
F2/AR
DI*01
139
on the thermocycler (Mastercycler gradient, EpAR
CAGGGCCAGGGAGGCCA
pendorf AG, Hamburg, Germany), at the followBF
GGTGGTGAAGTCCACGCC
(17)
BF/R
DI*02
129
ing conditions: denaturation at 95C for 5 min
R
CCAGGCAGCCACTCACAC
utes, then 30 cycles of 30 seconds at 95C, 30
seconds at 60C, and 90 seconds at 72C.17 The
HGH-F
TGCCTTCCCAACCATTCCCTTA
(18) HGHF/
HGH
434
reactions were completed by an elongation step
HGHR
for 5 minutes at 72C. PCR products were visuHGH-R CCACTCACGGATTTCTGTTGTGTTTC
alized in a 2% agarose gel stained with ethidium

GenBank accession no. AC003043 for SLC4A1


bromide under 100 V using photodocumentation
F = indicates forward primer; R = reverse primer.
equipment (Eagle-eye; Stratagene, La Jolla, CA).
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

67

M.C.Z. Novaretti et al.

and for determination of the Tm (melting temperature at


which double-strand DNA is broken down to single-strand
DNA) for DI*01 (86.94C) and DI*02 (88.04C) (Figure 2).
Of 62 samples tested, 49 were found to be homozygous for
DI*02. Eleven were DI*01/02, and two were DI*01/01. Our
results for DI*01 and DI*02 genotyping with real-time PCR
were totally concordant with those obtained by PCR-SSP.
The two samples with a DI*01/01 genotype by PCR-SSP allowed us to establish and validate the detection of the DI*01
homozygous allele by real-time PCR.

Fig. 1. PCR-SSP typing for DI*01 and DI*02 alleles. A 434-bp


fragment of HGH was amplified as an internal control. Lane M
shows a 100-bp ladder. (A) DI*01 was determined by the presence
of 139-bp fragment. From left to right: Blank (lane 1), DI*01-positive
samples (lanes 2, 3), DI*01-negative (lanes 4, 5), DI*01-positive
control (lane 6). (B) DI*02 allele was determined by the presence
of specific PCR product (129-bp).From left to right: DI*02-positive
control (lane 1), Blank (lane 2), DI*02-positive samples (lanes 3, 4,
5, 6, 7, 8, 9) and negative control for DI*02 (10).

Comparison of Phenotyping with Hemagglutination,


PCR-SSP, and Real-time PCR for DI*01 and DI*02
The sensitivity of our real-time PCR assay was verified
by correctly identifying 160 samples for DI*01 and DI*02
by serology, PCR-SSP, and real-time PCR. Of these, 127
were found to be DI*02/02 and 33 were DI*01/02. No
single DI*01/01 sample was identified in this series. All homozygous and heterozygous alleles have been distinguished
by melting curve analyses. Although no DI*01 homozygous
individual was found in this series, we tested two DI*01/01
samples in the validation step, and both were also identified by real-time PCR. Our results of Diego genotyping using real-time PCR were consistent and totally concordant
with those results obtained using PCR-SSP. No discrepant
results were observed among the three methodologies evaluated in our study.
Analysis of Diego Genotype and Allele Frequencies
in Brazilian Blood Donors
Phenotype frequencies were estimated in Brazilian
blood donors (Table 2). Among 4326 blood donors tested,
4169 (96.4%; 95% confidence interval [CI], 95.896.9%)
were homozygous for DI*02 and 157 (3.6%; 95% CI, 3.1
4.2%) were DI*01/02 heterozygous. No blood donor was
found to be homozygous for DI*01 in this study (Table 2).
We assumed that no blood donor presented the very rare
band 3deficient phenotype for Diego genotype and allele
frequency calculation. The calculated DI*01 and DI*02 allele frequencies were 0.0181 (95% CI, 0.01730.0189) and
0.9819 (95% CI, 0.97910.9847), respectively, showing a
good fit for the Hardy-Weinberg equilibrium (Table 3).
Table 2. Diego phenotype incidence in 4326 Brazilian blood donors
Phenotype

Number

95% CI

Di(ab+)

4169

96.4

95.896.9

Di(a+b+)

157

3.6

3.14.2

Di(a+b)

Total

4326

100

2 = 1.4776.
CI = confidence interval.
Table 3. Allele frequencies of DI*01 and DI*02 in 4326 Brazilian
blood donors
Diego alleles

Allele frequency

95% CI

DI*01

0.0181

0.01730.0189

DI*02

0.9819

0.97910.9847

CI = confidence interval.

Fig. 2. Melting curve analysis of samples genotyped as (A)


DI*01/01, (B) DI*02/02,and (C) DI*01/02. The DI*01 and DI*02 Tm
were determined at 86.94 and 88.04C, respectively.The arrows
indicate controls (positive, negative) for DI*01 and DI*02, blank, and
sample donors tested.

68

Discussion
In the last 10 years, the vigorous globalization process
has made international travel and significant immigration
extraordinarily common. Rare blood can be necessary in
unexpected regions, causing an extra impact on blood services. Consequently, the Diego blood group system is of
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Real-time PCR in Diego genotyping

clinical importance not only in Latin America but also in


many other countries. Different approaches can be taken to
deal with this situation.

Diego phenotyping has not been routinely performed
in several blood services owing to the scarcity of commercial anti-Dia. The situation is critical for Dib, as there is no
available commercial anti-Dib. Therefore, whenever there is
a suspicion of anti-Dia or -Dib, two problems are faced: one
is to confirm the antibody specificity against the Diego antigens with appropriate controls (negative and positive), and
the other is to find units negative for the antigen involved.

This need led us to search for an alternative approach
for Diego blood group antigen testing and for the selection
of blood units negative for Dia or Dib. Diego genotyping can
be performed using the PCR-SSP method. However, PCRSSP is a time-consuming assay as it requires post-PCR handling, and it has been shown to be inadequate for large-scale
implementation.20

Wu et al.17 described a PCR-SSP method for DI*01 and
DI*02 genotyping that we used in this study. They tested
different primer combinations and tried to use a single tube
for PCR-SSP technique to identify DI*01 and DI*02 alleles
in the same reaction. However, the results were disappointing, and they had to use two tubes, generating two separate
products. Consequently, we used two separate protocols to
test for DI*01 and DI*02 by PCR-SSP.

Real-time PCR for DI*01 and DI*02 allele determination can overcome these drawbacks because it allows specific amplification without post-PCR manipulations. Moreover, real-time PCR decreases the risk of error by the simple
fact that it reduces the number of manual steps.21 Recently,
Polin et al.22 also described the methodology for real-time
PCR as an effective tool for blood group genotyping.

As labeled probes are costly when compared to realtime PCR with SYBR Green I, we decided to use the latter
for cost reduction.23 This decision also optimized our strategy for DNA analysis of other blood group systems, as we
saw no need to purchase special primers.

The real-time PCR protocol that we developed allowed
us to use the same primers we had been using for PCR-SSP
in a universal cycling program, performing the same protocol to identify DI*01 and DI*02 alleles. The advantages of
this real-time PCR method are the rapid performance and
the detection of two alleles in the same run. The PCR assay
revealed 100 percent specificity as assessed by comparison
of genotype data to those generated by serologic typing. The
Diego genotyping method described here, based on SYBR
Green I by real-time PCR, can be used as a high-throughput
discrimination of the DI*01 and DI*02 alleles (Figure 2).
This approach takes advantage of the fluorescent property of SYBR Green I and of the melting curve analysis for
the detection and discrimination of amplicons differing in
length and nucleotide content.

One limitation of this study is that we were not able to
detect the rare band 3 mutation called Coimbra, because
we had not tested all samples by the three methods chosen.
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

However, it would be highly unlikely to find one, as to date


band 3 Coimbra mutation has been associated with anemia, and we only included nonanemic individuals (blood
donors) in our study.13

Finally, we analyzed DI*01 and DI*02 genotype and
allele frequencies in 4326 Brazilian blood donors. There
are significant differences of DI*01 and DI*02 allele expression among world populations. The DI*01 allele is
considered rare in Whites,24,25 but is characteristic in
some Asians and in South American Indians with a gene
frequency as high as 40 percent.1,4 We detected Dia in 3.6
percent of blood donors, with a DI*01 gene frequency of
0.0181, indicating the complex ancestry miscegenation of
the Brazilian population. This study was conducted in So
Paulo State, located in southern Brazil, which is characterized by lower levels of African and higher degrees of European contributions when compared with other Brazilian
groups.26 Moreover, our results can be explained in part
by the successive migratory waves from 1500 to the 20th
century that contributed to the formation of the multiethnic highly admixed Brazilian population. This heterogeneity was documented in several genetic studies, which
demonstrated a typical although nonuniform triethnic (European, African, and Amerindian) population gene pool.27

In conclusion, we developed a real-time PCR protocol
for DI*01 and DI*02 genotyping that is feasible and easy
to perform on a high-throughput scale. It can improve and
facilitate anthropologic and epidemiologic studies on DI*01
and DI*02 allele determination.
Acknowledgments

We are indebted to Vitor Medeiros, Selma de Abreu,
and Silvia Leo Bonifacio for their suggestions and technical support.
References
1. Layrisse M, Arends T, Sisico R D. Nuevo grupo sanguneo encontrado en descendientes de Indios. Acta Med
Venez 1955;3:1328.
2. Levine P, Robinson EA, Layrisse M, et al. The Diego
blood factor. Nature 1956;177:401.
3. Thompson PR, Childers DM, Hatcher DE. Anti-Dib:
first and second examples. Vox Sang 1967;13:3148.
4. Mochizuki K, Ohto H, Hirai S, et al. Hemolytic disease
of the newborn due to anti-Dib: a case study and review
of the literature. Transfusion 2006;46:45460.
5. Ishimori T, Fukumoto Y, Abe K, et al. Rare Diego blood
group phenotype Di(a+b), I. Anti-Dib causing hemolytic disease of the newborn. Vox Sang 1976;31:613.
6. Uchikawa M, Shibata Y, Tohyama H, et al. A case of
hemolytic disease of the newborn due to anti-Dib antibodies. Vox Sang 1982;42:912.
7. Daniels GL. Human blood groups. Oxford, UK: Blackwell Science, 2002:35268.

69

M.C.Z. Novaretti et al.

8. Issitt PD, Anstee DJ. The Diego blood group system,


In: Applied blood group serology. 4th ed. Durham, NC:
Montgomery Scientific Publications, 1998:581607.
9. Thompson C. Diego(a) antigen frequency and antiDiego(a) frequency in South Texas community. Clin
Lab Sci 2006;19:2035.
10. Lux SE, John KM, Kopito RR, Lodish HF. Cloning and
characterization of band 3, the human erythrocyte
anion-exchange protein (AE1). Proc Natl Acad Sci U S
A 1989;86:908993.
11. Byrne KM, Byrne PC. Review: other blood group systemsDiego, Yt, Xg, Scianna, Dombrock, Colton,
Landsteiner-Wiener, and Indian. Immunohematology
2004;20(1):508.
12. Bruce LJ, Anstee DJ, Spring FA, Tanner MJA. Band 3
Memphis variant II. Altered stilbene disulfonate binding and the Diego (Dia) blood group antigen are associated with the human erythrocyte band 3 mutation
Pro854 Leu. J Biol Chem 1994;269:161558.
13. Alloisio N, Texier P, Vallier A, et al. Modulation of
clinical expression and band 3 deficiency in hereditary
spherocytosis. Blood 1997;90:41420.
14. Novaretti MCZ, Jens E, Camargo RL, et al. Anti-Diego B
in a Caucasian patient and the frequency of Diego blood
group system in blood donors. Portuguese [Anti-Diego
B em paciente caucasiana e a frequncia do sistema Diego em populao de doadores de sangue]. Bol Rev Soc
Bras Hematol Hemot 1994;16:302.
15. Novaretti MCZ, Jens E, Chamone DAF, et al. Comparison of tube and gel techniques for antibody identification. Immunohematology 2000;16:138141.
16. Hincley ME, Huestis DW. Case report. An immediate
hemolytic transfusion reaction apparently caused by
anti-Dia. Rev Fr Transfus Immunohematol 1979;22:5815.
17. Wu GG, Su YQ, Yu Q, et al. Development of a DNAbased genotyping method for the Diego blood group
system. Transfusion 2002;42:15536.
18. Gassner C, Schmarda A, Nussbaumer W, Schnitzer
D. ABO glycosyltransferase genotyping by polymerase
chain reaction using sequence-specific primers. Blood
1996;88:18526.
19. Chen EY, Lioa YC, Smith DH, et al. The human growth
hormone locus: nucleotide sequence, biology and evolution. Genomics 1989;4:47997.

20. Veldhuisen B, van der Schoot CE, de Haas M. Blood


group genotyping: from patient to high-throughput donor screening. Vox Sang 2009; 97:198206.
21. Araujo F. Real-time PCR assays for high-throughput
blood group genotyping. Methods Mol Biol 2009;
496:2537.
22. Polin H, Danzer M, Prll J, et al. Introduction of a realtime-based blood-group genotyping approach. Vox
Sang 2008;95:12530.
23. Sousa TN, Sanchez BA, Cervolo IP, et al. Real-time
multiplex allele-specific polymerase chain reaction for
genotyping of the Duffy antigen, the Plasmodium vivax
invasion receptor. Vox Sang 2007;92:37380.
24. Simmons RT. The apparent absence of the Diego (Dia)
and the Wright (Wra) blood group antigens in Australian aborigines and in New Guineans. Vox Sang
1970;19:5336.
25. Kunierz-Alejska G, Bochenek S. Haemolytic disease of
the newborn due to anti-Dia and incidence of the Dia
antigen in Poland. Vox Sang 1992;62:1246.
26. Parra FC, Amado RC, Lambertucci JR, et al. Color and
genomic ancestry in Brazilians. Proc Natl Acad Sci USA
2003;100:17782.
27. Leite FPN, Santos SEB, Rodriguez EMR, et al. Linkage disequilibrium patterns and genetic strucuture of
Ameridian and Non-Ameridian Brazilian populations
revealed by long-range X-STR markers. Am J Phys Anthropol 2009;139:40412.
Marcia C. Zago Novaretti, MD, PhD, Immunohematology
Division, Fundao Pr-Sangue Hemocentro de So Paulo,
Assistant Professor, Hematology Department, University
of So Paulo Medical School, Av. Dr. Enas Carvalho de
Aguiar, 155-1 andar, So Paulo, SPBrazil CEP 05403000; Azulamara da Silva Ruiz, MT, Immunohematology
Division, Fundao Pr-Sangue Hemocentro de So Paulo, So Paulo, Brazil; Pedro Enrique Dorlhiac-Llacer, MD,
PhD, Scientific Director, Fundao Pr-Sangue Hemocentro de So Paulo, Associate Professor, Hematology
Department, University of So Paulo Medical School, So
Paulo, Brazil; and Dalton Alencar Fisher Chamone, MD,
PhD, President, Fundao Pr-Sangue Hemocentro de So
Paulo, Professor, Hematology Department, University of
So Paulo Medical School, So Paulo, Brazil.

For information concerning the National


Reference Laboratory for Blood Group
Serology, including the American Rare
Donor Program, please contact Sandra
Nance, by phone at (215) 451-4362, by fax at
(215) 451-2538, or by e-mail at snance@usa.
redcross.org

70

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Review

The Dombrock blood group system: a review


C. Lomas-Francis and M.E. Reid
of donor blood. This review summarizes the understanding
of the Dombrock blood group system that has evolved as
methods were developed and applied.

The Dombrock blood group system (Do) consists of two antithetical antigens (Doa and Dob) and five antigens of high
prevalence (Gya, Hy, Joa, DOYA, and DOMR). Do antigens are
carried on the Dombrock glycoprotein, which is attached to
the RBC membrane via a glycosylphosphatidylinositol linkage.
The gene (DO, ART4) encoding the Do glycoprotein, located
on the short arm of chromosome 12, has been cloned and sequenced, allowing the molecular basis of the various Do phenotypes to be determined. Doa and Dob have a prevalence that
makes them useful as genetic markers; however, the paucity
of reliable anti-Doa and anti-Dob has prevented this potential
from being realized. The ease with which these antigens can be
predicted by analysis of DNA opens the door for such studies
to be carried out. Anti-Doa and anti-Dob are rarely found as
a single specificity, but they have been implicated in causing
hemolytic transfusion reactions. This review is a synthesis of
our current knowledge of the Dombrock blood group system.
Immunohematology 2010;26:7178.
Key Words: ART, blood group system,
Dombrock blood group system, monoADP-ribosyltransferase, ADP-ribosyltransferase

Table 1. The Dombrock blood group system


Reactivity with anti-

he Dombrock (Do) blood group


system illustrates the value of
different methods for the advancement of knowledge. Classical hemagglutination showed certain characteristics of the antigens and antibodies,
a relationship of Hy to Gya, and the fact
that the Gy(a) phenotype was the null
of the Dombrock blood group system.
Immunoblotting provided a tool to allow further characterization of the
Dombrock glycoprotein, including the
fact that it is linked to the RBC membrane by a glycosylphosphatidylinositol (GPI) anchor. In silico analysis
aided in cloning the DO gene and led
to PCR-based assays not only to identify the nucleotide changes associated
with the antigens but also to screen for
antigen-negative donors and identify
new alleles. Transfection and hybridoma technology has been used for the
production of monoclonal antibodies to
Do, and DNA array technology provides
a means to do high-throughput testing

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

History
Anti-Doa was identified in 1965,1 and anti-Dob, which
recognizes the antithetical antigen, was described 8 years
later.2 These two antibodies define three phenotypes, the
prevalence of which differs in various ethnic groups (Table 1). For populations other than Whites,2,4 studies have
been restricted to testing with anti-Doa, and thus the numbers given for Do(ab+) in Table 1 are calculated from the
prevalence given for Doa.46 Doa and Dob were placed in the
Dombrock blood group system (DO; 014) by the ISBT Working Party on Terminology for Red Cell Surface Antigens in
1985.7

Occurrence (%) in

RBC
phenotype

Do

Do

Gy

Hy

Jo

Whites

Blacks

Japanese

Thai

Do(a+b)

18

11

1.5

0.5

Do(a+b+)

49

44

22

13

Do(ab+)

33

45

76.5

86.5

Gy(a)

Rare

Rare*

Rare

Not
found

Rare

Hy

wk

wk

0/
wk

Not
found

Rare

Not found

Not
found

Not
found

Jo(a)

wk

0/
wk

wk

Not
found

Rare

Not found

Not
found

Not
found

Chinese

*One Gy(a) Black proband has been reported.3


One Gy(a) Chinese proband has been found (unpublished data).

RBCs will most often be Do(b) when the Do glycoprotein is encoded by JO/JO but Do(b+W)
when encoded by HY/JO.

71

C. Lomas-Francis and M.E. Reid


The high-prevalence antigens Gregory (Gya) and Holley (Hy), described independently in 19678,9 were shown to
be phenotypically related. RBCs from Caucasians with the
Gy(a) phenotype are Hy, and RBCs from Black people
of African descent with the Hy phenotype are Gy(a+w).10
On the basis of this observation, Gya and Hy were upgraded from the ISBT Series of High Incidence Antigens to the
Gregory Collection (206) (Table 2).11 Gya and Hy were shown
to be located on the same glycoprotein by immunoblotting
in 1991.12
Table 2. ISBT terminology for the Dombrock (014) blood group
system antigens
Traditional
name

ISBT name

Doa

DO1

014001

Dob

DO2

014002

Gya

DO3

014003

206001;
900005

Hy

DO4

014004

206002;
900011

Joa

DO5

014005

901004;
900010

DOYA

DO6

014006

DOMR

DO7

014007

ISBT number

Previous ISBT
number


The high-prevalence antigen Joa was first described in
197213 and later shown to have a phenotypic association
with Gya and Hy because RBCs with either the Gy(a) phenotype or the Hy phenotype are also Jo(a).14,15 Joa was
assigned a number in the ISBT Series of High Incidence Antigens before its association with Gya and Hy was realized.7
When Joa was shown to reside on the Gregory glycoprotein
by immunoblotting,16 it was not placed in the Gregory collection but it was promoted directly to the Dombrock blood
group system.17,18 Another high-prevalence antigen, Jca, was
shown to be associated with Gya and Hy,19 and although it
was reported to be the same as Joa,20 there remained some
doubt and an ISBT number was not assigned to Jca. On the
basis of subsequent work, this doubt was justified (see later
discussion).21

In 1992, Banks and coworkers22 revealed that in addition to being Hy and Jo(a), Gy(a) RBCs were Do(ab).
Thus, it was shown that RBCs with the Gy(a) phenotype
are the null phenotype of the Dombrock blood group system.23 After this discovery, Gya, Hy, and Joa were assigned
ISBT numbers in the Dombrock blood group system (Table
2).17,18
Dombrock Glycoprotein

Antigens in the Dombrock blood group system are carried on a GPI-linked glycoprotein.12,16,24 The Dombrock glycoprotein has an apparent Mr of approximately 47,000 to
58,000 in SDS-PAGE under nonreducing conditions.12,23
In the membrane-bound form, the Do glycoprotein has

72

five potential N-linked glycosylation sites and four or five


cysteine residues.25 The susceptibility of some Do antigens
to sulfhydryl compounds suggests that the tertiary conformation of the glycoprotein is dependent on disulfide
bonds.

The Do glycoprotein is expressed primarily on erythroid cells in adult bone marrow and in fetal liver. Expression may also occur in the lymph nodes (on lymphocytes),
testes, spleen, and fetal heart. Although the Do glycoprotein
is a member of the mono-ADP-ribosyltransferase family, no
enzyme activity has been demonstrated on the RBC. ADPribosyltransferases catalyze the transfer of ADP-ribose from
NAD+ to a specific amino acid in a target protein that modulates protein function. ADP-ribosylation can be reversed by
ADP-ribosyl hydrolases, which remove the ADP-ribose and
restore protein function.26,27 Thus, Do may be involved in
the regulation of cellular protein function.
Dombrock Antigens

The characteristics of antigens in this system are summarized in Table 3. The susceptibility and resistance of antigens in the Dombrock system to treatment of RBCs with
various proteolytic enzymes and DTT, and their absence
from paroxysmal nocturnal hemoglobinuria (PNH) type III
RBCs,24 can be used to aid the identification of antibodies to
Dombrock antigens.
Table 3. Characteristics of antigens in the Dombrock blood group
system
Resistant to papain or ficin treatment of antigen-positive RBCs. Often the
reactivity is enhanced.
Sensitive to trypsin treatment of antigen-positive RBCs.
Doa, Dob, Gya, Hy, DOYA, and DOMR are sensitive to DTT (200 mM)
treatment of antigen-positive RBCs. Joa is variably affected by such treatment. All antigens are resistant to treatment of antigen-positive RBCs
with 50 mM DTT.
Weakened by -chymotrypsin or AET treatment of antigen-positive RBCs.
Expressed on cord RBCs; although Gya, Hy, and Joa may be weaker than
on RBCs from adults.
Absent from PNH III RBCs.
Some variation in expression on different RBCs and on RBCs from different people.
Carried on a mono-ADP-ribosyltransferase (ART-4), a GPI-linked protein.
Doa, Dob, Hy, and Joa are not highly immunogenic.

AET = 2-aminoethylisothiouronium bromide; GPI = glycosylphosphatidylinositol; PNH = paroxysmal nocturnal hemoglobinuria.

Dombrock Antibodies

Studies involving the Dombrock blood group system
have been hampered by the paucity of reliable monospecific antisera. Antibodies in the Dombrock blood group system can be difficult to identify. This is especially true for
the differentiation of anti-Hy from anti-Joa. As will be described later, determination of the molecular basis associated with Hy and Joa has provided an explanation for this

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Dombrock blood group system

particular difficulty. Common characteristics of antibodies


to Dombrock blood group system antigens are summarized
in Table 4.
Table 4. Characteristics of antibodies to Dombrock antigens
Usually IgG.
React optimally by column agglutination technology or by the IAT using
papain- or ficin-treated RBCs.
Usually weakly reactive.
Do not bind complement.
Stimulated by pregnancy and by transfusion.
Usually present in sera containing other alloantibodies. The exception is
anti-Gya, which often occurs as a single specificity.
Often deteriorate in vitro and fall below detectable levels in vivo.
Have not caused clinical HDFN (positive DAT only) but have caused
transfusion reactions.

HDFN = hemolytic disease of the fetus and newborn.

Clinical Importance

Although transfusion reactions caused by anti-Doa
or anti-Dob have been reported,2837 they may be underreported. One reason is that events usually associated with
transfusion reactions may not be observed. For example,
the DAT is often negative, no antibody is eluted from the
patients RBC samples after transfusion, there is no lag
phase in the antibody reactivity, and no increase in titer of
the antibody is observed. However, in our experience, the
provision of Do(a) or Do(b) blood as predicted by DNA
analysis has improved RBC survival in patients with the
corresponding antibody who receive chronic transfusions.
At least one anti-Hy has caused biphasic destruction of Hy+
RBCs38; other examples of anti-Hy, and anti-Gya and antiJoa, have caused moderate transfusion reactions. In the absence of Gy(a) blood, Hy blood has been a suitable substitute (personal observations). Some anti-Gya appear to
be benign: 10 Gy(a+) units were transfused to a man with
anti-Gya without adverse consequences.39 Antibodies in the
Dombrock blood group system typically do not cause clinical HDN, although RBCs of some antigen-positive babies
were positive in the DAT. One baby of a mother with antiDOMR was born icteric and required phototherapy.40
The DO Gene

For some time, it has been known that DO is located on
the short arm of chromosome 12 (Fig. 1).41 In silico analysis
aided in identification of a candidate DO gene, which has
been cloned and sequenced (GenBank accession number;
AF290204).25 DO is the first blood group gene to be cloned
by an in silico approach.42

The DO gene is identical to ART4, described in 1997
(GenBank accession number X95826),43 and has been renamed DO (GenBank accession number NM_021071,
AF290204). The data sets for the chromosomal arms of
ART3 and ART4 were inadvertently switched,43 so ART4
was incorrectly reported to reside on the long arm of chromosome 12. Had it not been for this switch, it is likely that
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

ART4 would have been recognized as the DO gene in 1997!


Although the original publication for ART4 did not include
exon 1,43 the entire sequence of ART4 is identical to DO (F.
Koch-Nolte, personal communication). Cloning and sequencing of DO allowed the determination of the molecular
basis associated with various Do phenotypes (see later discussion) and led to PCR-based assays to screen for antigennegative donors and identify new alleles.

The DO gene consists of three exons distributed over 14
kilobase pairs (kbp) of DNA (Fig. 1). The messenger RNA,
which consists of 1.1 kbp, is predicted to encode a protein of
314 amino acids that has both a signal peptide and a GPIanchor motif (Fig. 1).25 Both these are cleaved and not present in the membrane-bound form of Do. The DO*B allele
encodes an Arg-Gly-Asp (263-RGD-265) motif. RGD motifs within adhesive ligands are commonly involved in cellto-cell interactions involving integrin binding.44 However,
because the DO*A allele, and the chimpanzee DO (pDO)
homolog, encode asparagine (N) instead of aspartic acid
(D),25,45 it is unlikely that the RGD motif encoded by the
DO*B allele is a critical one.46
q

p12.3

A
DO

DO*01/DO*02

5
ATG

10,982

1,816

3
Stop

314
Do glycoprotein
Signal
Peptide

GPI-anchor
Motif

Fig. 1 Diagram of DO, its organization, and the Do glycoprotein. (A)


Location (12p12.3) of DO on the short arm of chromosome 12. (B)
The organization of the three DO exons. (C) The Do protein with signal
peptide at the amino terminus and glycosylphosphatidylinositol (GPI)anchor motif at the carboxyl terminus.

Molecular Basis of Antigens and Phenotypes


The Polymorphic Doa (DO1) and Dob (DO2) Antigens

The common forms of DO*A and DO*B alleles differ in
three nucleotide positions in exon 2. Two are silent nucleotide changes (378C>T, Tyr126Tyr; 624T>C, Leu208Leu);
the third is a missense change (793A>G, Asn265Asp), which
encodes, respectively, Doa and Dob (Table 5).25 These three
nucleotide changes can be readily differentiated by PCRRFLP, using DraIII for 378C>T,47 MnlI for 624T>C,47 and
BSeRI for 793A>G.49 Allele-specific PCR also can be used to
differentiate DO*A from DO*B.50 The ability to distinguish
DO*A from DO*B makes it feasible to predict the Do type of
patients and blood donors. This is a tremendous advantage
73

C. Lomas-Francis and M.E. Reid

because, owing to the paucity of reliable reagents, screening


for large numbers of Do(a) or Do(b) blood donors using
classical hemagglutination methods has not been feasible.

Table 5. DO alleles defining phenotypes


Nucleotide
change

Exon

Amino acid
change

Phenotype

ISBT allele
name

DO:1 or
Do(a+)

DO*01 or
DO*A

DO:2 or
Do(b+)

DO*02 or
DO*B

793A>G

Asn265Asp25,47

DO:4 or Hy

DO*02.04

323G>T

Gly108Val21

DO:5 or
Jo(a)

DO*01.05

350C>T

Thr117Ile21

DO:6 or
DOYA

DO*01.06

547T>G

Tyr183Asp48

DO:7 or
DOMR

DO*02.07

431C>T;
432C>A

Ala144Glu40

Reference allele DO*01 (AF290204; shaded) encodes Doa, Gya,


Hy, Joa, DOYA, and DOMR antigens.See Table 6 for alleles that
result in the Gy(a) phenotype.

ISBT proposed allele name pending ratification June 2010.

The High-Prevalence Gya (DO3) Antigen



An absence of Gya, in addition to an absence of all antigens in the Dombrock blood group system, defines the
Donull [Gy(a)] phenotype. To date, DO has been described
to be silenced by five molecular bases (Table 6). Two of
them, a mutation in the donor splice site52 and a mutation
in the acceptor splice site,51 lead to outsplicing of exon 2.
The third mechanism is a nonsense change in a DO*A-HA
allele [350C; 378T (DO*B); 624T (DO*A); 793A (DO*A),
see later section].52 A fourth proband has a deletion of eight
nucleotides within exon 2 that leads to a frameshift and a
premature stop codon,53 and the fifth is attributable to an
amino acid substitution of Phe62 to Ser.54
Table 6. Molecular basis for Gy(a) phenotype
Phenotype

Allele name

Nucleotide
change

Exon

Amino acid
change

DO:3 or
Gy(a)

DO*02N.01

IVS12 a>g

Skips exon
251

DO:3 or
Gy(a)

DO*02N.02

IVS1 +2 t>c

Skips exon
252

DO:3 or
Gy(a)

DO*01N.03

442C>T

Gln148Stop52

DO:3 or
Gy(a)

DO*01N.04

343de1343
350

Frame-shift;
premature;
stop codon53

DO:3 or
Gy(a)

DO*01N.05

185T>C

Phe62Ser54

Changes from the reference allele (GenBank accession number


AF290204) are given.

The background for this allele is actually DO*A-HA (378T, 524T,


793A).55

ISBT proposed allele name pending ratification June 2010.

74

The High-Prevalence Hy (DO4) Antigen



The nucleotide change associated with Hy+/Hy phenotypes is 323G>T in exon 2, which is predicted to encode
Gly108Val. The change is associated with the absence of Hy
and is on an allele carrying 378C (DO*A), 624C (DO*B), and
793G (DO*B) (Table 5). Its association with 793G (265Asp)
explains why RBCs with the Hy phenotype are invariably
Do(ab+). There are two forms of the allele giving rise to
the Hy phenotype, one with 898G (300Val) and the other
with 898C (300Leu). Nucleotide 898C (300Leu) is present
on the allele encoding the wild-type Hy+. As the 898G allele
was present in the sister of the original Hy proband it was
named HY1, and the HY allele with the wild-type nucleotide
898C, HY2.21 Testing with one potent example of anti-Joa
showed that some Hy RBCs express Joa very weakly.56
The High-Prevalence Joa (DO5) Antigen

A single nucleotide change of 350C>T in exon 2 is
predicted to encode isoleucine at amino acid residue 117.
Nucleotide 350T is associated with the absence of the Joa
antigen and is predominantly on an allele carrying 378T
(DO*B), 624T (DO*A), and 793A (DO*A) (Table 5). The
genotype of people whose RBCs have the Jo(a) phenotype can be DO*JO/JO or DO*HY/JO.21 Its association with
793A (265Asn) explains why most RBCs with the Jo(a)
phenotype are Do(a+b) (Fig. 2). RBCs from individuals
with the DO*HY/JO genotype will type Do(a+b+w).
Do(a+) or Do(b+)
Wild Type phenotype

Holley-negative
phenotype
NH2

NH2

108
117

Gly
Thr

144

Ala

183

Tyr

265

Asn/Asp
Doa/Dob

Do(a+) or Do(b+)
Gy+ Hy+ Jo(a+)
DOYA+ DOMR+

Joseph-negative
phenotype

108

265

DOYA-negative
proband

NH2

Val

117

Asp

265

Do(ab+w)
Gy+w Hy Jo(a+w/)
DOYA+w DOMR+w

DOMR-negative
proband

NH2

NH2

Ile

Asn

Do(a+wb)
Gy+ Hy+w Jo(a)
DOYA+ DOMR+

183

Asp

265

Asn

144

Glu

265

Asp

Do(ab)
Do(ab+)
Gy+w Hy+w Jo(a+w) Gy(a+w) Hy+w/ Jo(a+w)

DOYA DOMR+w

DOYA+w DOMR

Fig. 2 Diagram showing amino acids associated with the various Do


phenotypes. The effect of the amino acid changes associated with
Hy, Jo(a), DOYA, and DOMR phenotypes on the other Do antigens is given under each stick figure. The figures for the DOYA and
DOMR phenotypes are each based on the only known proband.

The Jca Antigen



DNA analysis on four samples that had been originally typed as Jc(a) revealed a combination of DO*HY and
DO*JO alleles (DO*HY1/HY1; DO*HY1/HY2; DO*HY1/
JO; DO*JO/JO). These results show that Jca is not a discrete antigen.21

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Dombrock blood group system

The High-Prevalence DOYA (DO6) Antigen



The nucleotide change associated with DOYA+/DOYA
phenotypes is DO*A.547T>G in exon 2, which is predicted
to change Tyr183 to Asp (Table 5). In the DOYA Turkish
Kurd proband, this change silenced the expected Doa, so her
RBCs typed Do(ab). They also have a weakened expression of Gya, Hy, and Joa (Fig. 2).57


Chapel-Fernandes and coworkers60 measured the expression of various Do proteins on transduced K562 cells by
flow cytometry using monoclonal anti-Do. They report that
the protein encoded by DO*B-SH, DO*B-WL, and DO*BSH-Q149K alleles was expressed in lower copy number than
the protein encoded by DO*B or DO*B-I175N alleles. This
finding may provide insights into the variable expression of
Dob on RBCs.

The High-Prevalence DOMR (DO7) Antigen



The novel nucleotide changes associated with DOMR+/
DOMR phenotypes are 431C>A and 432C>A, which are
predicted to encode Ala(GCC)144Glu(GAA) (Table 5). The
change is associated with the absence of the DOMR antigen and is on a DO*B-WL allele (see later section). Its association with 793G (265Asp) explains why RBCs with the
DOMR phenotype are Do(b+), albeit weakly. RBCs from
the DOMR Brazilian Black proband have a weakened expression of Gya, Hy, and Joa (Fig. 2).40

DO and Anthropology

The chimpanzee DO allele has the human wild-type
nucleotides at positions 323, 350, and 898 and has 378T
(DO*B), 624C (DO*B), and 793A (DO*A).21 This sequence
has not been found in humans and does not provide an insight as to the primordial DO gene. The sequence of the allele
from three unrelated chimpanzees was identical (GenBank
accession numbers AF373016, AF373017, and AF374727).
Transfection of DO cDNA

Cells transfected with DO cDNA have been used to study
expression levels of Do.25,60 Cells transfected with DO cDNA
have also been used as an immunogen to produce several
monoclonal antibodies (MoAbs). Two MoAbs, MIMA-52
that recognizes a DTT-sensitive epitope and MIMA-53 that
recognizes a DTT-resistant epitope, strongly agglutinate
RBCs from humans [except Gy(a)] and other great apes
but not from lesser apes, old world monkeys, new world
monkeys, prosimians, rabbits, dogs, sheep, or mice.45 Three
other MoAbs (MIMA-64, MIMA-73, and MIMA-98) agglutinated RBCs from humans, chimpanzees, greater apes, and

Other DO Alleles

Testing of DNA from Blacks from Brazil or the Congo
led to the recognition of additional DO alleles. These are
DO*A-HA,55 DO*A-SH,58 DO*A-WL,59 DO*B-SH,55 DO*BWL,58 DO*B-SH-Q149K,60 and DO*B-I175N (it is possible
that this last allele could be on a DO*B-WL background)
(Table 7).60 The initials used in these allele names are derived from the initials of investigators who reported them.
Information is lacking about the nature of the Do glycoprotein or antigenic expression, if any, encoded by these alleles.
These alleles are not known to encode novel antigens.

Table 7. DO alleles, including some that were described only at the DNA level
Allele name

nt (aa)

nt (aa)

Nt

nt

nt (aa)

nt (aa)

nt (aa)
Other

ISBT

Other

323 (108)

350 (117)

378

624

793 (265)

898 (300)

DO*01

DO*A

G (Gly)

C (Thr)

A (Asn)

C (Leu)

DO*01.05

DO*JO

G (Gly)

T (Ile)

A (Asn)

C (Leu)

DO*01.06

DOYA

G (Gly)

C (Thr)

A (Asn)

C (Leu)

DO*A-HA

G (Gly)

C (Thr)

A (Asn)

C (Leu)

DO*A-SH

G (Gly)

C (Thr)

A (Asn)

C (Leu)

DO*A-WL

G (Gly)

C (Thr)

A (Asn)

G (Val)

DO*02

DO*B

G (Gly)

C (Thr)

G (Asp)

C (Leu)

DO*02.04

DO*HY1

T (Val)

C (Thr)

G (Asp)

G (Val)

DO*02.04

DO*HY2

T (Val)

C (Thr)

G (Asp)

C (Leu)

DO*02.07

DOMR

G (Gly)

C (Thr)

G (Asp)

G (Val)

DO*B-SH

G (Gly)

C (Thr)

G (Asp)

C (Leu)

DO*B-SH-Q149K

G (Gly)

C (Thr)

G (Asp)

C (Leu)

DO*B-WL

G (Gly)

C (Thr)

G (Asp)

G (Val)

DO*B-I175N

G (Gly)

C (Thr)

G (Asp)

C (Leu)

547T>G (Tyr183Asp)

431C>A and 432C>A (Ala144Glu)


445C>A (Gln149Lys)
524T>A (Ile175Asn)

Alleles defined only through DNA-based assay; not investigated serologically.


aa = amino acid; nt = nucleotide.

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

75

C. Lomas-Francis and M.E. Reid

lesser apes but not RBCs from the other animals (unpublished observations). A homolog of the DO has been found
in mouse,43 and thus the lack of reaction with mouse RBCs
indicates that the specific epitope recognized by the MIMA
anti-Do is restricted to apes.61
Expression of Dombrock Antigens

The molecular basis associated with Hy and Jo(a)
phenotypes was determined only after numerous samples
were analyzed. During this analysis, it became clear that
RBC samples had been misidentified. The most significant
was that of SJ after whom the Joseph phenotype and Joa
antigen were named. Surprisingly, DNA from SJ typed
DO*HY1/HY2 and DNA from her Hy+ brother was DOHY2/
DO*B.21 Thus, any anti-Joa that was identified by using SJ
RBCs may actually be anti-Hy. The use of such RBCs and
antibodies as reagents has led to the inadvertent incorrect
labeling of reagents. To correctly identify anti-Hy and antiJoa, RBCs whose type has been predicted by DNA analysis
should be used. The various possible combinations and expected antigen expression are given in Table 7. RBCs from
people with DO*JO/JO or DO*JO/HY genotypes will have
the same phenotype, although the latter may have a slightly
weaker expression of Hy.

The close proximity of amino acids associated with Hy
(residue 108) and Joa (residue 117) antigen expression may
explain why Hy RBCs lack or have an extremely weak expression of Joa and why Jo(a) RBCs have a weak expression of Hy (Fig. 2). The two critical residues are separated
by only eight amino acids, which is within the range of an
antigenic determinant.62,63 The reason for the weak expression of Gya on Hy RBCs, the weak expression of Dob on
RBCs with the Hy phenotype, and the weak expression of
Doa on RBCs with the Jo(a) phenotype is still not understood but likely involves conformation or the effect of steric
hindrance or charge on the conformation. Interestingly, the
amino acid changes involved with an absence of DOYA or
DOMR also weaken other Do antigens (Fig. 2).

It is apparent that the immune response in different
people with the same Dombrock phenotype varies. One
possibility is that Hy patients may produce anti-Doa in
addition to anti-Hy, and Jo(a) patients may produce antiDob in addition to anti-Joa. Furthermore, a patient with a
Jo(a) phenotype and a DO*HY/JO genotype should have
RBCs that type Do(a+wb+w) Gy(a+) Hy(a+w) Jo(a) and
thus would be expected to make only anti-Joa. The results
of DNA analysis of serologically identified samples with
unusual Do phenotypes provide an explanation for the diversity of typing results in antibody producers and for the
diversity of the reactivity of their plasma and serum of their
immune response.

76

Conclusions

Determination of the molecular basis underlying the
antigens in the Dombrock blood group system has several
advantages and has changed practice in transfusion medicine. The first, as outlined earlier, is the possibility of using
RBCs with a bona fide antigen profile in antibody identification studies. The second advantage is to predict the phenotype of patient RBCs to aid in the antibody identification
process; the third is the ability to type donors for DO*A and
DO*B and thereby select Do(b) RBCs for transfusion to a
patient who has or has had anti-Dob. Yet another value is
to be able to type donors whose RBCs are used in antibody
identification panels.64 This is, perhaps, the first instance
in which DNA analysis is more reliable than hemagglutination. This is because the antibodies (especially anti-Doa
and anti-Dob) are rarely available as a single specificity with
strength and volume to make accurate typing possible.

There is no known disease entity associated with the
Doa form of the Dombrock glycoprotein (RGDRGN) nor,
indeed, with an absence of the entire glycoprotein [Gy(a)].
The presence of RGN in the chimpanzee homolog21 suggests
that this, and not RGD, may be the primordial sequence. Expression of Dombrock and other ectoenzymes (Kell and Yt)
on RBCs may provide a readily transportable steady-state
level of these enzymes for tissues in the vascular space.
Acknowledgments

We are grateful to Friedrich Koch-Nolte of University
Hospital, Hamburg, Germany, and George Cross of the
Rockefeller University, New York, NY, for helpful discussions and Robert Ratner for help in preparation of the manuscript and figures.
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ME, Bailly P, Chiaroni J. Dombrock genotyping in a native Congolese cohort reveals two novel alleles. Transfusion 2009;49:166171.
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anti-Joa suggests that Holley-negative red cells do
express some Joa antigen (abstract). Transfusion
2001;41(Suppl):24S.
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analysis to the quality.
Christine Lomas-Francis, MSc, FIBMS (corresponding
author), Technical Director, Laboratory of Immunohematology, New York Blood Center, 4501 Vernon Boulevard,
Long Island City, NY 11101; and Marion E. Reid, PhD, Laboratory of Immunochemistry and Laboratory of Immunohematology, New York Blood Center, New York, NY.

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

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Clinical significance of antibodies in transfusion and HDN.
Number of compatible donors that would be expected
to be found in testing 100 donors. Variations in different
ethnic groups are given.
Characteristics of the antibodies and optimal technique(s)
for their detection.
Technical tips to aid their identification.
Whether the antibody has been found as an autoantibody.

Pocketbook Education Fund


The authors are using royalties generated from the sale of
this pocketbook for educational purposes to mentor people
in the joys of immunohematology as a career. They will
accomplish this in the following ways:
Sponsor workshops, seminars, and lectures
Sponsor students to attend a meeting
Provide copies of the pocketbook
(See www.sbbpocketbook.com for details to apply for funds)

82

Ordering Information
The book, which costs $25, can be
ordered in two ways:
Order online from the publisher
at: www.sbbpocketbook.com
Order from the authors, who
will sign the book. Send a check,
made payable to New York Blood
Center and indicate Pocket
book on the memo line, to:
Marion Reid
Laboratory of Immunochemistry
New York Blood Center
310 East 67th Street
New York, NY 10065
Please include the recipients
complete mailing address.

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Advertisements, cont.

Becoming a Specialist in Blood Banking (SBB)


What is a certified Specialist in Blood Banking (SBB)?
Someone with educational and work experience qualifications who successfully passes the American Society for Clinical Pathology (ASCP)
board of registry (BOR) examination for the Specialist in Blood Banking.
This person will have advanced knowledge, skills, and abilities in the field of transfusion medicine and blood banking.
Individuals who have an SBB certification serve in many areas of transfusion medicine:
Serve as regulatory, technical, procedural and research advisors
Perform and direct administrative functions
Develop, validate, implement, and perform laboratory procedures
Analyze quality issues preparing and implementing corrective actions to prevent and document issues
Design and present educational programs
Provide technical and scientific training in blood transfusion medicine
Conduct research in transfusion medicine
Who are SBBs?
Supervisors of Transfusion Services
Supervisors of Reference Laboratories
Quality Assurance Officers
Why be an SBB?
Professional growth

Managers of Blood Centers


Research Scientists
Technical Representatives

Job placement

LIS Coordinators
Consumer Safety Officers
Reference Lab Specialist

Job satisfaction

Educators

Career advancement

How does one become an SBB?


Attend a CAAHEP-accredited Specialist in Blood Bank Technology Program OR
Sit for the examination based on criteria established by ASCP for education and experience
However: In recent years, a greater percentage of individuals who graduate from CAAHEP-accredited programs pass the SBB exam.
Conclusion:
The BEST route for obtaining an SBB certification is
to attend a CAAHEP-accredited Specialist in Blood Bank Technology Program

Contact the following programs for more information:


Program

Contact Name

Phone Contact

Email Contact

Website

On site
or On line
Program

Walter Reed Army Medical Center

William Turcan

202-782-6210

William.Turcan@NA.AMEDD.ARMY.
MIL

www.militaryblood.dod.mil

On site

American Red Cross, Southern California Region

Michael Coover

909-859-7496

CooverM@usa.redcross.org

none

On site

ARC-Central OH Region

Joanne Kosanke

614-253-2740 x 2270

kosankej@usa.redcross.org

none

On site

Blood Center of Southeastern Wisconsin

Lynne LeMense

414-937-6403

Lynne.Lemense@bcw.edu

www.bcw.edu

On site

Community Blood Center/CTS Dayton, Ohio

Nancy Lang

937-461-3293

nlang@cbccts.org

http://www.cbccts.org/education/
sbb.htm

On line

Gulf Coast School of Blood Bank Technology

Clare Wong

713-791-6201

cwong@giveblood.org

www.giveblood.org/education/
distance/htm

On line

Hoxworth Blood Center, Univ. of Cincinnati

Susan Wilkinson

513-558-1275

susan.wilkinson@uc.edu

www.hoxworth.org

On site

Indiana Blood Center

Jayanna Slayten

317-916-5186

jslayten@indianablood.org

www.indianablood.org

On line

Johns Hopkins Hospital

Jan Light

410-955-6580

jlight5@jhmi.edu

http://pathology2.jhu/
department/divisions/trnafusion/
sbb.cfm

On site

Medical Center of Louisiana

Karen Kirkley

504-903-3954

kkirkl@lsuhsc.edu

none

On site

NIH Clinical Center Dept.. of Transfusion Medicine

Karen Byrne

301-496-8335

Kbyrne@mail.cc.nih.gov

www.cc.nih.gov/dtm

On site

Rush University

Veronica Lewis

312-942-2402

Veronica_Lewis@rush.edu

www.rushu.rush.edu/health/dept.
html

On line

Transfusion Medicine Center at Florida Blood


Services

Marjorie Doty

727-568-5433 x 1514

mdoty@fbsblood.org

www.fbsblood.org

On line

Univ. of Texas Health Science Center at San Antonio

Linda Myers

210-731-5526

lmyers@bloodntissue.org

www.uthscsa.edu

On site

Univ. of Texas Medical Branch at Galveston

Janet Vincent

409-772-3055

jvincent@utmb.edu

www.utmb.edu/sbb

On line

Univ. of Texas SW Medical Center

Barbara LairdFryer

214-648-1785

barbara.fryer@UTSouthwestern.edu

http://telecampus.utsystem.edu

On line

Additional Information can be found by visiting the following Web sites: www.ascp.org, www.caahep.org and www.aabb.org
IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Revised August 2007

83

Immunohematology
Immunohematology

Journal
SerologyAND
andEDUCATION
Education
JOURNAL of
OF Blood
BLOOD Group
GROUP SEROLOGY

Instructions tofor
theAuthors
Authors
Instructions
I. GENERAL INSTRUCTIONS
Before submitting a manuscript, consult current issues of
Immunohematology for style. Double-space throughout the manuscript.
Number the pages consecutively in the upper right-hand corner, beginning
with the title page.
II. SCIENTIFIC ARTICLE, REVIEW, OR CASE REPORT WITH
LITERATURE REVIEW
A. Each component of the manuscript must start on a new page in the
following order:
1. Title page
2. Abstract
3. Text
4. Acknowledgments
5. References
6. Author information
7. Tables
8. Figures
B. Preparation of manuscript
1. Title page
a. Full title of manuscript with only first letter of first word capitalized
(bold title)
b. Initials and last name of each author (no degrees; all CAPS), e.g., M.T.
JONES, J.H. BROWN, AND S.R. SMITH
c. Running title of 40 characters, including spaces
d. Three to ten key words
2. Abstract
a. One paragraph, no longer than 300 words
b. Purpose, methods, findings, and conclusion of study
3. Key words
a. List under abstract
4. Text (serial pages): Most manuscripts can usually, but not necessarily,
be divided into sections (as described below). Survey results and
review papers may need individualized sections
a. Introduction
Purpose and rationale for study, including pertinent background
references
b. Case Report (if indicated by study)
Clinical and/or hematologic data and background serology/molecular
c. Materials and Methods
Selection and number of subjects, samples, items, etc. studied and
description of appropriate controls, procedures, methods, equipment,
reagents, etc. Equipment and reagents should be identified in
parentheses by model or lot and manufacturers name, city, and state.
Do not use patients names or hospital numbers.
d. Results
Presentation of concise and sequential results, referring to pertinent
tables and/or figures, if applicable
e. Discussion
Implication and limitations of the study, links to other studies; if
appropriate, link conclusions to purpose of study as stated in
introduction
5. Acknowledgments: Acknowledge those who have made substantial
contributions to the study, including secretarial assistance; list any grants.
6. References
a. In text, use superscript, Arabic numbers.
b. Number references consecutively in the order they occur in the text.
7. Tables
a. Head each with a brief title; capitalize the first letter of first word (e.g.,
Table 1. Results of . . .) use no punctuation at the end of the title.

b. Use short headings for each column needed and capitalize first letter
of first word. Omit vertical lines.
c. Place explanation in footnotes (sequence: *, , , , , **, ).
8. Figures
a. Figures can be submitted either by e-mail or as photographs (5 7
glossy).
b. Place caption for a figure on a separate page (e.g. Fig. 1 Results of...),
ending with a period. If figure is submitted as a glossy, place first
authors name and figure number on back of each glossy submitted.
c. When plotting points on a figure, use the following symbols if
possible: .
9. Author information
a. List first name, middle initial, last name, highest degree, position held,
institution and department, and complete address (including ZIP
code) for all authors. List country when applicable.
III. EDUCATIONAL FORUM
A. All submitted manuscripts should be approximately 2000 to 2500
words with pertinent references. Submissions may include:
1. An immunohematologic case that illustrates a sound investigative
approach with clinical correlation, reflecting appropriate collaboration
to sharpen problem solving skills
2. Annotated conference proceedings
B. Preparation of manuscript
1. Title page
a. Capitalize first word of title.
b. Initials and last name of each author (no degrees; all CAPs)
2. Text
a. Case should be written as progressive disclosure and may include the
following headings, as appropriate
i. Clinical Case Presentation: Clinical information and differential
diagnosis
ii. Immunohematologic Evaluation and Results: Serology and
molecular testing
iii. Interpretation: Include interpretation of laboratory results,
correlating with clinical findings
iv. Recommended Therapy: Include both transfusion and
nontransfusion-based therapies
v. Discussion: Brief review of literature with unique features of this
case
vi. Reference: Limited to those directly pertinent
vii. Author information (see II.B.9.)
viii. Tables (see II.B.7.)
IV. LETTER TO THE EDITOR
A. Preparation
1. Heading (To the Editor)
2. Title (first word capitalized)
3. Text (written in letter [paragraph] format)
4. Author(s) (type flush right; for first author: name, degree, institution,
address [including city, state, Zip code and country]; for other authors:
name, degree, institution, city and state)
5. References (limited to ten)
6. Table or figure (limited to one)
Send all manuscripts by e-mail to immuno@usa.redcross.org

I M M U N O H E M A T O L O G Y, V O L U M E 2 2 , N U M B E R 4 , 2 0 0 6
84

215

IMMUNOHEMATOLOGY, Volume 26, Number 2, 2010

Musser Blood Center


700 Spring Garden Street
Philadelphia, PA 19123-3594

FIRST CLASS
U.S. POSTAGE
PAID
SOUTHERN MD
PERMIT NO. 4144